Macho Guy

Every man likes to think of himself as a macho, man's man sorta tough guy. After all, no boy ever spent his afternoons dreaming he'd grow up to be Elton John (not that there's anything wrong with being a softie).

No. When I was a kid, I'd dream of being Stringfellow Hawke (of Airwolf fame), or Michael Knight (gasp, yes, the Hoff's days in Knight Rider). Heck, I even spent afternoons dreaming I was He-Man (though it would be wrong since I also had a crush on She-ra, and as you all know, was his sister).

Now that I'm all grown up, I'd like to think that my juniors and students look up to me. Perhaps even my blog readers. And then I caught a glimpse of myself in the window reflection today,

But really, how macho can a guy be when he's wearing this? Funnily enough, I'm not complaining. She's totally worth it.

Allison is one month old!!

-- Sent from my Palm Pre

A Love-Hate Relationship

It's true, thyroidologists have a love-hate relationship with Amiodarone, and other iodine-containing agents.
This can cause hypothyroidism (failure to escape from the Wolf-Chaikoff effect) or hyperthyroidism. And in the latter, it can be either increased T4 formation from subclinical thyroid disease (such as Graves' or nodular thyroid, Type 1 Amiodarone-induced hyperthyroidism) or thyroiditis (so-called Type 2 Amiodarone-induced hyperthyroidism).
Problem from a diagnostic standpoint is, while the medical students/residents amongst you will say you can do a thyroid uptake and scan to differentiate between them, the gland's iodine binding sites are all already saturated with iodine from the Amiodarone and the uptake will invariably come back low. And while the websites/books talk about the sonographic appearance of the gland and IL3 and other markers, none are definitive.

As far as treatment is concerned, we're stuck in the same situation; you can't tell if this is thyroiditis versus increased synthesis of T4, and even if this was the latter you can't treat these patients using the conventional methods, antithyroids don't work too well because the thyroid is already iodine-laden. Ditto with radioablation- the I131 will only go from the GI tract to blood and straight back out in poo and pee. And, given that the half-life of Amiodarone is 100 days, stopping this (even if you could from a cardiac standpoint) does absolutely nothing for the near future. And so, you can only treat the patients symptomatically, try to use antithyroids knowing they don't work well for the lack of anything better, or in a sick-enough patient you may have to send this patient to surgery for a thyroidectomy.

Except most of these patients are at a high surgical risk anyway what with their arrhythmia. Think of Mr. X whom I've been seeing for the last 7 months and who has been on a high dose of Propylthiouracil 200 mg TID. He has ischemic cardiomyopathy and afib, and an implanted defibrillator that was periodically going off; surgery was the last thing his cardiologist wanted him to undergo. Thankfully, after 6 months of high dose PTU, and a course of Prednisone, I finally called him with the good news. His TSH and free T4 are now normal!

Phew!!

A Case of Hyperprolactinemia

A 28 year old woman presents for evaluation of hyperprolactinemia. She reports a history of irregular menses, and infertility for 10 months. She reports some breast tenderness and headaches, but denies any galactorrhea. Her last menstrual period was May 30th; she denies the possibility of pregnancy. There is no history of illicit drug use. Her physical examination is normal.

Laboratory testing included a Prolactin of 32 (normal less than 21), TSH 1.5 and normal electrolyte panel.

How would you proceed?

Answer: Hyperprolactinemia can be caused by multiple things, the more common ones I see are medication-related and prolactinomas. However, it's important to go back to basics when working these cases up; people can often be wrong (not that they were being malicious in the first place) so it's a good idea to do a confirmatory pregnancy test. In this case, this woman, despite her reassurance to me, turned out to be pregnant.

If the patient was not pregnant and was on no medication that can be implicated, and if the TSH is normal, the next step would be a pituitary MRI.

Bravo to those who answered.

Duck, What Duck?

Allison loves bathtime!

(Dear readers: now that I'm a proud new dad, you're going to see far too many baby pictures than you're probably wanting to. So I'll understand if you remove my blog from your usual reads. But if you're a parent yourself, you'll understand why even pictures of your baby's diaper is so fascinating)

I got this from Mrs. N the other day. It was a little gift for baby Allison, a homemade quilt, and a card.

I had been seeing Mrs. N since I started working in this group. She was a 60-something year old woman, a dear old thing. Her primary doc sent her to me for management of her diabetes, because she was "a hopeless case" (her words). Despite being on an insulin pump, they were just not able to bring down her sugars. And she did not care for the huge expense they were paying for the pump.
And so I did the unthinkable- I had her get rid of her pump, and got her back onto the good-ole-Multiple Daily Insulin program. A cheaper and proven program, albeit not as fancy as the pump.

I can't say we've gotten her A1c down to 7% yet. However it did go from >14% to 12% to 9.8% to 9.0% to her most recent of 8.2%. She was supposed to have come in for a visit with me on June 24th. However you all know what happened to me that day, but as with the many other patients the clinic had to reschedule, she was very gracious about things when she was told my wife was in labor.

So when I did see her a couple of days ago, she gave me a firm hug and a kiss, and congratulated us for the beautiful baby. She also gave us the handmade quilt, while I proudly shared my baby pictures with her. Coincidentally that was the day Kristin brought the baby by to work to show to my colleagues, and it was a bonus that Mrs. N got to see Allison.

I have to say, one of the most rewarding aspects of this job is the relationships I've had the pleasure of forming. Unlike my alma mater (well, being a trainee probably had something to do with it too) where things were always very professional and formal, now that I'm out on my own (well as part of a group) I've been a lot more laid back with patients and have gotten to know them much better.

And in Mrs. N's case, this was one of the few cases in which I shared my email with a patient and told her to email me whenever she had problems with her sugars, so that we didn't have to adjust things only during our visits. And so, painfully slowly but surely, things got better. And when I gave her her report card of 8.2% this week, she gave me a bearhug.

It's things like these that make this job worthwhile.

A Case of Acromegaly

I saw Mr. J for the first time a week ago.
I was floored as I stepped into the room.
Acromegaly, it seemed clear to me.
A condition of increased growth hormone by a pituitary tumor.
He exhibited most of the striking features, including large hands and feet, prominent forehead and jaw with some coarsening of features, large nose and tongue. He also had numerous skin tags, and colon polyps, which was the reason his gastroenterologist sent him to me.
I had his IGF-1 levels drawn, amongst other labs. I did caution him I expected to find that elevated and the next step when confirmed would be a pituitary MRI, cardiac echo (as part of the pre-op evaluation as some of these patients will have cardiomyopathy- a good thing to know before you embark on surgery) and a neurosurgical consult. My resident though didn't seem impressed- he thought the patient looked not-too-abnormal.
I wasn't the least bit surprised when his levels came back 5x above normal.
The thing was, he was initially a bit upset that his family doctor whom he has been seeing for years, did not pick this up.
The truth is, this is usually the case, I told him. The changes are so slow and so subtle, that often the people who have known you the longest are the ones who are least likely to notice the clinical picture. Even Mr. J himself who wasn't sure why his gastroenterologist sent him to me. He and his wife denied all the usual questions I asked him, including change in shoe size, ring, etc. He thought he looked pretty normal. Simply because of the extremely slow progression.
I remember what Dr. Y said in fellowship:
"This is the kind of disease a doctor new to the patient is most likely to detect, not someone who has known the patient for years."
So true.
One helpful tip I gave my resident who was working with me that day. I asked Mr. J if he had any older pictures. He pulled out a 9-year old government ID and we compared it to his present phenotype. And with that, my young trainee doctor was convinced.

How do you bid farewell to one of your best friends, your confidante, your roomate of 5 years?

Easy, it is not.

But today, we had a chance to visit with Buddy and his wife, who after 10 years of being away from home for undergraduate and postgraduate medical training, TEN YEARS, they are finally heading home next week to begin their new chapter of readjusting to life in Malaysia. Ten long years, which included an ongoing battle with esophageal cancer, but also of many many wonderful events of weddings, birthdays, amongst friends and what we've come to see as 'family' here.

I do catch myself thinking though, of how as we go on with our own lives and plant our own roots, friends do part ways (at least in distance, thankfully never in spirit, even those I don't get to see often anymore). The numerous buddies I grew up with whom I left behind in Malaysia. The friends of which I had the honor of meeting in our 6 years in Rochester. I miss them all.

Good luck, guys, and safe travels.