But No One Told me I am Diabetic, Doc!

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Hi. It’s Dr. Louella in a sombre mood today. I keep thinking about this patient I had today in chronic disease clinic; a young guy in his thirties.

No drama here. I started off with my usual verification of what the patient suffers with. I’ve been doing that a while now, since discovering that patients attend our clinics for years with only a vague idea of what they’re being treated for.

I don’t know if it’s a Trinidadian thing with the responses I receive but I’ve asked this question so many times that I’m no longer surprised…

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‘What are you suffering with sir/madame?’

Some patients get offended. They start to stammer that I am the doctor and therefore I should know. So I let them know it’s a big file (we use handwritten patient notes) and we would move a lot faster if they tell me rather than me having to go through all these notes.

Furthermore I remind them that they are the patient. It is their health and their responsibility to know what they are afflicted with.

‘So, would you like to tell me, sir/madame, what are you suffering with?’

There are other patients who begin everything with ‘they say’. For example that, ‘They say I have diabetes’. When I try to confirm that they mean that they have been diagnosed with diabetes, they respond consistently, ‘So they say’. So in my estimation, they are in huge denial!

Sometimes I would make a check in the notes only to find that they have had this said to them for five years or more. I let them know that ‘they’ say it only because it is true and it’s very important they learn to accept it and deal with it.

Then there are those patients who try to respond correctly but leave out diagnoses. When I check the notes there may be an additional diagnosis such as ischaemic heart disease or chronic kidney disease that they are clueless about and which they sometimes deny vehemently.

So then I need to backtrack to find out where that came from, if they were diagnosed at hospital or presumed to have the disorder or what. I need to know if a diagnosis is true or not to convey this to the patient sitting in front of me.

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Finally there are patients who give additional diagnoses to what are documented. Something may have happened since the last visit or more likely they had been suffering with some disorder and didn’t think it necessary to inform us.

Our patients attend several different doctors, clinics and institutions simultaneously. Very little official information is shared between these groups.

It is often up to the patient to let us know what is going on. To some of them it is a secret. Others forget or don’t think it relevant. Me, I grab up this stuff, because I want to know everything.

I use the diagnosis as a starting point to inform and educate the patient. It’s not that you maybe sometimes could probably have hypertension. You HAVE it and you need to deal with it. It’s not about a bunch of numbers but really debilitating complications that you could get but we are trying to prevent.

Getting back to the case at hand… When I had my usual discussion with this young man about his diagnoses today, I was a bit thrown. He knew he was overweight and had elevated cholesterol but knew nothing about having had diabetes.

But it was staring at me in his notes! He was newly diagnosed as a diabetic on the previous visit. Apparently he had not been told. Oops! That was a problem. And he seemed intelligent enough that he would have remembered.

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I proceeded to take the time to double check his blood investigations. Those results pointed to pre-diabetes, which as I explained to him, was in between ‘normal’ and ‘diabetic’. He was becoming diabetic. Steps had to be taken to try to prevent, or at least delay, full blown diabetes.

(The term ‘Impaired Glucose Tolerance’ is an older term that was and is still used for this condition. I much prefer the simpler ‘pre-diabetes’ when dealing with patients as ‘pre-‘ indicates ‘before’.)

While advising the patient about his condition, I needed to reassure him as well. He had been started on the appropriate medication (metformin). I actually increased his meds for now because his glucose level was high.

I advised him strongly about weight loss, that that in itself may reverse his condition and referred him to the dietitian (they make our life so much easier).

I spoke a lot about exercise because I know that if you’re not into it, it could take you a while to get started. I wanted to get him thinking that this thing was doable.

I threw out different ideas of different types of exercise he could attempt and explained how the day-to-day routine he described was physical activity but not intense enough to be classed as exercise. And he had the size to show for it.

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In the end he was really grateful for the information. But of course, other patients were waiting.

I really feel passionate about helping younger patients prevent and manage chronic diseases. That’s why I spend extra time with them.

It is often more difficult for them to come to terms with their illnesses than older adults. They want to enjoy their youth and do not want to be saddled with strict diets and medication.

I let them see that I take their health seriously and they should too. But I also try to inspire hope within them because without it they wouldn’t even try.

I will continue to ask patients the question ‘What are you suffering with’ or seek verification from the patient as to his/her diagnoses because it is important. It is only when people properly understand what is going on with them can they make informed decisions and live healthier lives.

I feel better now that I’ve shared that. I’d like to think I am making a difference in this world, one dot at a time. Dr. Louella is out!!!

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My Name is ANXIETY!!!

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Hi, Dr. Louella again. I want to chat with you about anxiety today. This comes off our talk on insomnia, where I realized that anxiety was the cause of my recent bout of insomnia.

Now, this is not a treatise on anxiety. It is just want to make you more aware of it and how to deal with it. I am in the advantageous position of both having studied and treated people with anxiety disorders and having suffered anxiety myself. Advantageous? Yes, I know both ends of the stick and it is a good feeling when what you’ve been through can benefit someone else.

Now, I’m not going to pretend that I am cured of anxiety because it is usually not that easy. But I am managing it so that it does not interfere with my life. That’s the key, how functional you are. And I do function!

Well, what is anxiety to begin with? The very essence of it is fear. It may be disguised as concern or worry. It is a negative respond to stress. We allow ourselves to ruminate or obsess over a situation because we are afraid of something going wrong in the future or are unable to let go of the hurts of the past.

Anxiety is basically a human emotion which we all feel. It can be useful in small doses. Say you are crossing a road. Next thing you see a truck come speeding out of nowhere. The anxiety you feel can catapult you to the other side of the road. That’s our “fight or fight” response due to adrenaline (‘epinephrine’, to the Americans), and we surely need it.

But there are other times when that response is misplaced. Your daughter goes out with a friend, and as the night draws later you start to worry more and more about her safety in these times of high crime. You think you have a right to worry about her as a parent. But do you? Examine it with me for a while.

You will be evoking in your body a similar but milder ‘fight or flight’ response with your worry. Hormones are going to be released. Your heart beats faster, blood pressure will elevate, digestive system is suppressed, muscles tense up, but unlike in the previous example, there is no action. You can’t run across the road and save her! You can do nothing.

You get your body in this hyped up state and the excess fuel is not used for any physical activity. Normal bodily functions are suppressed when we are ‘stressed’, including the ability to fight off diseases. You are like this, yet you can do nothing to help your daughter. I let my patients know they’re not helping her, and they’re certainly not helping themselves with their worry.

So now, imagine if you do this repeatedly. Everyday there is something new to worry about: the state of the economy, the package delivered late, the traffic conditions, murder, the failed dinner, the sick child, the list is exhaustive. What happens in our minds? What happens to our bodies?

You may be surprised by what a negative response to stress does to our bodies. Remember, everyone is faced with stressful situations on a daily basis. But we don’t all respond the same. Something one person throws over the shoulder, another person laughs at and yet another rants and raves about. So, it is not the actual stressor but our response to it that affects our bodies.

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When we respond with frequent expressions of fear such as concern, worry, fretting and anxiety, it affects us physically. We are constantly putting our bodies on alert to act but never do. Chronic anxiety affects us through: dizziness, fast heartbeat, fatigue, headaches, inability to concentrate, irritability, nausea, rapid breathing, trembling, digestive disorders, memory loss and premature heart attack.

Look again at those symptoms. Don’t you get some of those from time to time? I have sooo many otherwise healthy patients who come in with the symptoms above. I automatically think ‘stress’ when I see a young woman with mild dizziness. More often than not, there is a huge stressor in her life that she is not coping well with.

And isn’t everyone ‘tired’ or has lack of energy these days? What about stomach problems and memory loss? Hey! I’m not saying we simply dismiss these symptoms as stress-related but it is important to be aware, especially in general practice, that you may not be able to find an actual physical cause of a problem. The possibility that there are psychological factors triggering symptoms is real.

But, being a doctor and knowing my body, if I ever feel dizziness I say to myself, “Girl, you are stressing over something. You didn’t realize, huh?” And when I am forgetting a whole lot, I know I need a rest. When my acid reflux resurfaces, I don’t take meds. I just make a note to myself that I’m stressed.

I must re-direct you to the symptoms one final time. Do you see why you need a good night’s sleep before exams? For memory and concentration. And how could a healthy corporate executive just keel over with a heart attack? Extreme stress. Ever notice you’re just sitting there but you’re breathing hard?

So the long and short of it is that anxiety and excessive stress are not good for our bodies, especially as cortisol suppresses our immune system making us more susceptible to diseases. When I’m stressing myself out a lot I think, “You’re killing yourself girl; shortening your life. Stop it!”

But really, I would like to take you more inside the mind of an anxious person (you may well find that mind is your own) because it’s no big taboo. All of us get anxious, some more so than others. I want to teach you to be able to recognize the state and be able to get out of it quickly.

Ok, so I gotta go now. Will chat more later in the week. I have got an hour and 30 min to get to church, and for me, that ain’t enough. I’m not like my sis who needs an hour. Ciao!!!