What was wrong with my patient?

It took a nurse's bedside observation to help me solve this medical mystery.

By M.P. Ravindra Nathan, MD

When I first saw 65-year-old Patrick, he seemed very ill. At 5 feet 10 inches and 137 pounds, he was practically skin and bones. Thoughts of cancer, uncontrolled diabetes, and thyrotoxicosis raced through my mind. I wondered why he had waited so long to seek medical care.

Patrick was hearing-impaired and I had difficulty getting a medical history. He turned up the volume on his hearing aid, but I still had to shout. Apparently he had come to my cardiac clinic because he'd been experiencing heartburn during his morning walks. Asked why he was so thin, he simply shrugged and said, "Oh, I've been underweight for some time now. I guess that's the way my body is."

Patrick's wife had passed away nearly three years before, but he looked happy and was at times garrulous. If he had any sadness, he internalized it well. He didn't have much help with cooking and cleaning. "TV dinners are my friends now," he said. "I don't know what I'd do without them."

The physical exam was unrevealing, except that he was a bit dehydrated. The electrocardiogram was mildly abnormal with nonspecific changes that raised the possibility of ischemia, so I admitted Patrick to the telemetry unit for further workup. Initial blood tests and chest X-rays were within normal limits, but his exercise stress test with nuclear imaging suggested that he did indeed have coronary artery disease.

I scheduled Patrick for a cardiac catheterization, and my associate notified me of a 90 percent lesion in the left anterior descending artery that looked ideal for angioplasty. Since we didn't have cardiac surgical facilities, Patrick was transferred to the nearby regional heart center and underwent a successful angioplasty. He should be okay now, I thought with relief.

At his follow-up exam a month later, Patrick was symptom-free but still dehydrated. Moreover, he was ashen, fatigued, and down to 135 pounds. He had lost his appetite, he told me. I was sure there was an occult malignancy somewhere. So I readmitted him for another battery of tests. A repeat stress test was negative for myocardial ischemia. The consulting oncologist declared him free of cancer. His mild anemia was expected to correct itself with improved diet and iron supplements. Upper and lower endoscopies were unrevealing. When he was ready to be discharged, the dietitian sat him down and reviewed basic lessons in nutrition and healthy cooking.

One month later, Patrick was in the ER. This time, it was hematuria and renal colic. The urologist reported a small stone in the left ureter that would probably pass with fluids and diuretics. He had lost another two pounds. One of the nurses with experience in pediatrics said his diagnosis should be "failure to thrive."

The following morning Deanna, the night nurse, called me and said, "Dr. Nathan, I've observed Patrick during all his admissions and I talked to him at length last night. He's been very lonely since his wife died. His only son hasn't kept in touch with him and he has no friends in the neighborhood."

"Do you think he's depressed?"

"Very much so," Deanna answered. "He told me, 'Every afternoon, I sit in my patio chair and think about my wife and the sweet life we had. We retired to Florida to enjoy our golden years, but we were not so lucky. I've been a good person all my life . . .' Then his voice trailed off and there were tears in his eyes."

I started Patrick on antidepressants. A consulting psychiatrist diagnosed him with situational depression. "You know," the psychiatrist said, "there is bereavement and depression, and we need to differentiate the two. Patrick is more than sad. He is clearly depressed."

The social worker arranged for Patrick to get hot meals daily from the local Meals on Wheels program. We encouraged him to participate in church activities. Nurtured by personal and social contacts, he became more energetic and started gaining weight. At his next checkup, he'd put on three pounds. Not a giant leap, but tangible progress nevertheless. When I saw Deanna, I didn't forget to tell her, "Thanks to you, Patrick is a lot better now."

Sometimes we don't realize that external appearances can be deceptive. Aging, with all its attendant medical problems, financial concerns, and loss of spouse and cohorts, sometimes leads to depression. But some depressed patients put on a mask. Unless you lift the mask, the Patricks of your practice will continually "fail to thrive."

The author is a cardiologist in Brooksville, FL, and a member of the Editorial Board of Medical Economics.

 

M.P. Ravindra Nathan. What was wrong with my patient? Medical Economics Nov. 21, 2003;80:55.