Sunday, July 30, 2006

Early Satiety

Welcome, old and new readers and friends! Thank you so much to my loyal readers for your encouragement and kind words. I'm glad to be writing again, and I'm so touched you've continued to read my work.


Early Satiety

"I’m getting fat! How do I stop gaining all this weight?"

My patient throws her thin arms into the air and looks at me. Her abdomen sits rotund, larger than a 42 wk pregnancy, and her sleeves are loose and parachute-like. She tells me she used to be able to eat four hamburgers; now, she can only finish half of one before she feels full. At night, she can no longer lie flat without becoming short of breath from the weight of her insides pressing on her. She is 66 and has not had a period since the 1970’s. She has a history of breast cancer, status post radiation and mastectomy. She also had a vaginal hysterectomy for fibroids, and she opted to keep her ovaries.

In addition, she is a wonderful person. The nurses and CNA's love her. A regular in the Resident Clinic, she and her husband collect Social Security and Medicare, and the Clinic is situated conveniently on their bus line. I might be the fifth resident to have her in my three-year long Continuity Clinic.

"Good Lord, look at me! What is the deal?" she says, wiping the sweat from her brow. She's been easily tired. The weight started to pile on quickly in the last six months.

When I present the patient's case to my clinic attending in a nearby lounge, he shakes his head. "The nice-person, negative-prognosis sign," he says. I nod. I know what he's talking about--mean patients tend to be less likely than the pleasant ones to pass away.

I filled out a lab form that included a CA-125 and a CT scan of her abdomen and pelvis, in addition to an array of other serum levels. I walk quickly back to the room and tell her we are looking for something that may cause all this fluid.

"Like what?"

"I don’t want to alarm you."

"Like another cancer?"

"We’re not sure. We want to be sure."

"Isn't it all just fat?"

"I don't know. It could be."

"I mean, look at it!" At this point, she grabs her belly and tries to lift it off the chair. I try not to laugh while she shakes her head and lets out her own laugh, then a sigh.

"OK. Do what you need to do, Doctor. Just make sure Medicare covers all this."

I wondered to myself, if I hadn’t been an intern in OB/GYN for a year, if I hadn’t seen all those women with ovarian cancer, their abdomens sometimes so filled with malignant ascites they couldn’t breathe at night, would I have come to the same conclusion about the patient in front of me, in a general medicine clinic?

I hoped, Maybe it IS all a pannus. But the fluid wave. I couldn’t ignore a fluid wave. Her abdomen seemed to grow exponentially. It had to be ascites, but why? Her lungs were clear. A recent ECHO showed no evidence of heart failure. A set of liver function tests from last year was normal.

The last patient I took care of with ovarian cancer lived and died during my first internship, on my rotation in Gynecology-Oncology. I can still remember what her cries sounded like, and what her smile looked like. Her case infused my thoughts even when I was at home, though I tried not to let it. I knew it wasn't wrong to feel things while at work, but I didn't want to feel too much. I didn't want my emotions to hamper my job.

Seeing this new patient in front of me, this funny, pleasant, kind woman who brings her health to me and asks me to help take care of it, I know it is useless to hold back. If what happened to me with the previous patient repeats itself, then let it. If it hampers my job, it might also make me a better doctor.

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