I want to share with you an interaction I had with a patient, which illustrates the importance of ensuring you establish a relationship with a primary care provider and visit them with some regularity.
This message is especially directed to all of you men out there.
Yes… us guys are really terrible at taking care of ourselves. It’s very interesting to think about how well we maintenance our automobiles, appliances, homes, electronic devices and how little this attention to detail and care is directed towards our own bodies.
30 years without maintenance
A 59 year old male presented to the clinic with chief concerns of appetite change and weight loss. Peripheral to his chief concerns, we recognized his gait was off and he sat in what we call in antalgic position, likely because of some serious low back pain he suffered. In addition, he looked very pale and unwell.
He had a few abnormal vital signs, a pulse averaging between 118-122 and a blood pressure of low 100s/60s on repeated measures.
“Something just isn’t right,” he said. “I haven’t eaten much in the last two days and my appetite has been pretty diminished over the last few months.”
“Have you seen anyone else since this all started happening?”
“No. I haven’t been to a doctor in 30 years.”
Yikes…
We learned he had suffered 15 pounds of unintentional weight loss over the last 3 months. And most recently his fare had been reduced from burgers and fries a few times a day to a few crackers.
A review of systems revealed issues most likely related to an enlarged prostate. He had trouble initiating urination and noted some dribbling whenever he would finish. Further, he suffered pretty severe nocturia, causing him to rise at least 8 times nightly to use the restroom.
In addition to the findings mentioned above, his physical exam revealed spooning of the nails, a finding often related to anemia, poor capillary refill and pain upon palpation of his lower abdomen. His digital rectal exam revealed prostate enlargement.
No bueno.
More evidence confirming no bueno
The labs we had ordered STAT returned revealing:
Normocytic anemia, electrolyte and protein abnormalities, an elevated BUN:Creatinine ratio, and elevations in liver enzymes.
But most ominous:
A prostate specific antigen of 2526 (normal >4), a CRP of 427.3 (normal 0-4.9), a ferritin of 18,210 (normal 30-400) and an alkaline phosphatase of 1861 (normal 39-117).
Based upon his clinical presentation and blood work, the working diagnosis is prostate cancer, probably with metastasis to at least the bone and/or liver.
Your body has dashboard lights
Think about the dashboard of your car. On mine, there’s a light for the oil pressure, for the transmission and of course the one everyone knows about – the check engine light. When something goes wrong with the car, the lights turn on and that’s your cue to take the car to the mechanic!
Now, away from the dashboard light mechanism, there are regular intervals that you take your car in for routine maintenance. This is something generally everyone does and for good reason. You don’t want to be operating this one to two ton piece of machinery in an unsafe manner, right? The stakes are very high.
Oftentimes the lights go off and the issue is so specific that little effort is required in maintenance. For instance, your oil light goes off indicating it is time for an oil and filter change. Maybe the signs point to something very specific, like a veering off to one side indicating that your alignment off or your windshield wipers start scratching your windshield, indicating you should change the darn wipers!
All of these are things you can take care of yourself, referring to an owners manual and spending a few minutes doing.
But when that check engine light goes off, frequently there are no obvious signs. Further, the check engine light is not specific for anything. You could have a faulty oxygen sensor, your fuel delivery system could be off, or you could have a loose engine mount.
The point is, there’s much more to this than simply referring to the owners manual or making this a quick DIY job.
Analogous to the check engine light are signs and symptoms we express when we are sick. You can think of a rash, fatigue, weight loss, or headaches as a check engine light of sorts. For one thing, our body does not come with an owner’s manual. And if it did, one might expect it take to years of study and experience to understand. And like the check engine light on a car, these issues are very non specific, meaning there are a lot of reasons or disease states that could explain the symptom.
There are exceptions, which we call pathognomonic findings in medicine. You might think of these sort of in the same way you would your brake light. The brake light definitely means something is wrong with your brakes. An example would be an X-ray showing bamboo spine, which points to ankylosing spondylitis.
Like the mechanic, a physician looks at the constellation of signs and symptoms and puts them together with your story in order to figure out what is going on. This is done when the dashboard lights go on and hopefully at regular intervals to ensure there is no catastrophic damage to the car.
Prevenir… you only get one
There’s a saying that goes “an ounce of prevention is worth a pound of cure.” This is one of our most important principles in medicine. We have so many amazing advances today that sometimes take care of catastrophic events, but these tools you do not want to be at the mercy of.
This highlights the importance of involving a doc you see regularly in the maintenance of your body. You only get one.
What’s very interesting is that the research on general health screening doesn’t clearly show that taking the car in at regular intervals actually reduces the number of poor outcomes [1].
There’s a number of reasons for this that have to do with the limitations from research design and inclusion of older studies where health checks were done without the fancy screening tools available today.
But a huge factor that comes to mind is the quality of care provided during those screening events.
How often is your physician taking the time to very sensitively look at your case? Looking at your lifestyle in depth and doing further investigation outside of the box? And then educating you on the tools needed to prevent disease?
These days, you’re super lucky if your primary care provider goes beyond 10 minutes or even puts their hands on you!
Nevertheless, regular checkups still continue to be a standard component of medical practice. And for a good reason.
Back to our case
It’s hard to say whether or not the outcome above could have been avoided. Oftentimes, things like this creep up on the individual with little warning. But what we do know is that this individual had relevant family history and several risk factors meshed into his lifestyle and the demographic he falls under.
The opinion of some is that he is essentially $%^&ed at this point. I’m always hard pressed to jump to that conclusion, but the cards are definitely stacked against him.
When was the last time you’ve visited a doctor?
Further Reading:
The research on general health screening and outcomes
The author:
Billy Mitchell is a medical student wrapping up his 4th year at Southwest College of Naturopathic Medicine. His areas of interest include rheumatology and environmental medicine.