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Wednesday, September 15, 2010

Life at Grady: The "Healthy" Patient

A version of the following post, by Kimberly Manning, FACP, appeared on the blog Life at Grady.

"My blood pressure is still borderline? Man!"

"Yeah...and from looking through the chart, it was 150/96 on your admission. It's pretty much been that since you've been here, give or take a few points. That's a little more than borderline, actually." I paused for a moment, realizing that I sounded a bit discouraging. "I don't think this would be hard to get under control at all, sir. I mean...you're such a motivated patient, you know?"

I studied my patient carefully. He was in his late thirties, although he could totally pass for a twenty-something all day, every day. His skin looked like someone had grabbed him by the tip of his toe and uniformly dipped him in milk chocolate--not a single blemish anywhere.

"I eat right and I exercise...in fact, I'm a health nut! I'm really kind of surprised that my pressure keeps running high."

(Click "more" below to continue reading this post.)

"You're not a smoker, no?" I asked.

"Smoker? Eeew! Hells no. I hate cigarettes!" He gave a playful shudder and then laughed. His pristine white teeth were almost too white...their perfect alignment was like seeing a tabloid celebrity up close and personal. He gave me a smirk and added, "Now my boyfriend? Hmmphh. That's another story. He smokes those nasty cancer sticks. Ugggh."

"Oh yeah?" I responded with a smile. "You'll have to get him in here--before his lungs do." He shook his head and curled his lips in a way that suggested the discussion of getting his partner to quit smoking was an old battle and a lost cause. I pictured him standing on the porch nagging his better half or covertly dumping half of a pack of Marlboros down the toilet. I raised my eyebrows in amusement.

For a brief second it dawned on me how completely unfazed I was by his reference to a "boyfriend" (as opposed to a "girlfriend" or a "wife".) I thought about how, way back in medical school, such inferences caught me by surprise, and then later in residency seemed to be almost a novelty. I'd find myself launching into these exaggerated "girlfriend" , finger-snapping interactions with such patients; I now realize these were probably deeply offensive.

"Now I bet a 'health nut' must be a total nag to a smoker!"

"Chile...I know that's right!" He chuckled but became more serious when looked down at the blood pressure cuff still wrapped around his arm. "And wouldn't you know--his blood pressure is frickin' LOW! Go figure." He let out a frustrated sigh.

This patient was used to being healthy. He was young, active, and for the most part, in pristine physical condition. He'd come to us after a fairly soft admission for what the emergency department called community acquired pneumonia. The initial portable chest x-ray demonstrated a questionable infiltrate, but his follow up two-view films were essentially unremarkable. A slightly low white blood cell count of 3,700 coupled with his endorsement of male sexual partners led to concern about the possibility of HIV. Upon further history, our team learned that this patient had been with his partner for nearly ten years, and was as boringly monogamous as it gets. The HIV antibody test was negative, and it was explained to him that lower white blood cell counts weren't unusual at all in African-Americans (to which he replied, "Yeah, I knew that already.")

At this point, it was time to discharge him. He looked awesome, and seemed like someone who would reliably follow up and do all that was asked of him. But his blood pressure just kept on reading a little too high for my comfort level. Not so high that he'd need to stay hospitalized, but definitely too high to keep referring to as "borderline."

"What about alcohol?" I asked, remembering the lecture my friend and fellow Grady doctor had recently given the residents on hypertension management. I recalled her teaching point about how excessive alcohol consumption can take your blood pressure up more than most folks realize. It was pretty much all I had left.

"I drink some. Not much, though."

"Oh okay. So like, what is 'some?'"

"Oh Lord, I don't know, Dr. Manning. Like a few margaritas here and there? Like a bunch of us love to hang out at El Azteca--that patio is so much fun--especially in the summer. So I'll have a few when I'm out there."

"I love El Azteca," I commented while thinking of the large outdoor seating area that, now that I thought of it, was always teeming with young attractive men who seemed interested in, well, each other. "Is that one of your summer hangouts?"

"Oh yeah, baby. That's the spot in the summer!" We shared a lighthearted laugh.

"When you go there or anywhere, what would you say is the most drinks you have?"

He sat for a minute and gazed skyward in thought. "Hmm, like...maybe three? Of the bigger ones, not the tiny ones," he admitted. "But I'm always eating and never driving."

Whoa! I recalled one of the last times my husband and I had enjoyed a meal at El Azteca. I ordered one lime margarita--the small one--and felt super-swimmy in the head before I could even finish it. Even Harry could "feel" his--so much so that we had to sit on that patio for nearly two hours drinking water so we could drive home.

"So tell me this," I asked. "If one of the large margaritas counts as two drinks, how many drinks would you say you have in a week?"

"A full week? Counting wine at night and stuff like that?"

"Sure, including everything."

He started counting his fingers and making funny expressions of exaggerated embarrassment. "If you count it like that, doctor...like...damn. Eighteen to twenty. That's bad, huh?"

"Well, it's more alcohol that you probably realize, you know? It can make your blood pressure run higher, too."

"Shut up!" he exclaimed putting his hand over his mouth. "Really?"

"Yep. Like for a man, you really shouldn't have more than four drinks in a day and more than fourteen for the whole week. It's less for us girls."

"Damn."

"Another question--are you drunk from the margaritas?"

"You know...I just have a high tolerance. I mean, I definitely get loose," he paused to giggle, "but I ain't falling down or cussing folks out or nothing. I definitely feel the buzz, but it's manageable. I'm just chillin'."

"Yeah, I hear you. I could tolerate more alcohol when I was younger and having liquor more regularly. Now I can't even take the little margarita at El Azteca. You know, I'm not picking on you...I just wanted to tell you...." I carefully spoke. "There's this saying that I think of when it comes to drinking alcohol."

"What's that?" He hung onto my every word. I was glad that he seemed so interested in my opinion and what I'd say next.

"Basically it goes something like this: 'The only way you can drink like that, is if you drink like that'."

"Wow," he said nodding slowly first, and then mid-nod changing to head shaking.

I went on. "It's kind of like when my friend was telling me how to prepare to run a half marathon. I asked her what the key was to running long distances and she said, 'Here's the key to running long distance: Run long distances. The only way you can run long distances is if you run long distances'."

"Wow," he repeated. It really seemed to resonate with him. Turns out that this health nut was doing something that wasn't so healthy after all.

In the end, we printed out a guide for alcoholic beverages and how to gauge what "one drink" is. He agreed to limit himself to no more than three equivalent drinks in a day and no more than seven in a week (he chose the seven over the recommended fourteen.) We started him on a low dose of an anti-hypertensive and also reviewed low sodium eating. (The other thing about El Azteca is that, like all yummy Mexican fare, it's SAL-TY.)

Today I'm reflecting on how easy it is to get into health problems from bad habits that we don't see as bad habits. The other thing is, I guess I always thought of heavy drinkers as staggering, boisterous, rabble-rousers...stumbling over tables and spitting while they spoke in their slurred speech. But they aren't. They hold jobs, are attractive, are romantically attached, and are functional folks. In fact, a lot of heavy drinkers are the picture of health--just like my patient.

"And no salt on the rim, right?" my patient called out to me as he and his partner passed me in the hallway on their way out.

I smiled and gave him a thumbs up from across the nurses station and watched him disappear down the corridor, confident that he would do exactly as he'd promised.

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posted by Jessica Berthold at 7:00 AM  

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internist and ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

CasesBlog
Ves Dimov, MD, ACP Member, is an allergist/immunologist and Assistant Professor of Medicine and Pediatrics at the University of Chicago, where he evaluates and treats both pediatric and adult patients.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
ACP Member Mike Aref, MD, PhD, ACP Member, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, ACP Member, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Musing of an Internist
Justin Penn, MD, ACP Associate Member, attended medical school at the University of Washington School of Medicine and trained in internal medicine at the University of Rochester, where he is serving as Chief Resident.

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

White Coat Underground
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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