Bipolar is more than a label

23-year old Jennifer was in today with husband Todd and step-daughter. Despondent, she had just just dropped all of her college courses and has not slept for 2 weeks. I thought we were making progress only 3 weeks ago when we found the proper combination of medications to clear her migraine headaches...even figuring out that her perfume was a trigger. But now she has not slept, her weight is slipping away and her anorexic patterns are returning. She finally admits to her depressed feelings, though it goes completely against her religious faith and her attempts to generate the gratitude and joyfulness that her cognitive brain understands to be true. Because of her lack of sleep I am suspicious of bipolar depression, and if I put her on a typical SSRI antidepressant such as Prozac or Zoloft, I could trigger a manic episode. I downloaded the Goldberg Screen for Bipolar Depression from the internet and administered the screening questions. She is positive for 11 out of 12 questions. I think she is bipolar, presently depressed, and in danger of serious anorexia. I will get her in to a psychiatrist as soon as possible. Unfortunately, the health care system is broken in that I can not refer her directly to someone. The psychiatrist will only accept an appointment made by the patient, so tomorrow I will need to call to make sure she has an appointment.

Life across the generations

The Montoya family was in today. This is why what I do is called "family" practice. Two-year-old Nadelis was in for her well child check, and to follow up on pneumonia. She is bright-eyed, tall, smiling and talking constantly. She answers questions in English or in Spanish, seamlessly changing languages though she is not aware of it. She is at that magical age where language is exploding. Every day new words appear and she delights in the attention she gets for her accomplishments. Her parents are attentive and delighted with her. It is an easy visit for me.

I was thankful that my nurse put her great grandmother, Adeleine, age 85 in a separate room, with her daughter. There I could inquire more deliberately about her blood pressure, still out of control after adding a medication last time. Immaculately groomed, elegant, and proper, Mrs. Montoya exuded the pride of being honored as the matriarch of her family, surrounded by her children and attended by them. I made an adjustment in her medication and will see her back in a couple of weeks to be sure that her blood pressure is coming under control.

Four generations from this family spead over 80+ years of age. It's not possible to be their physician without being a member of their family too.

What will become of Madeleine?

Madeleine was sleeping poorly. The 8-year-old girl who had always been a joy to have in my office stopped sleeping about 3 months ago. She won't fall asleep until 2 am, and she is afraid to go to sleep, afraid of monsters and sounds in the night. Of branches scratching the house and the wind. When she does get to sleep she gets up screaming uncontrollably, or she is up walking around the house in the middle of the night but not really aware of what she is doing. She is sleepwalking. And because she gets so little sleep, she can't get up in the morning for school. She's tired at school and beginning to be irritable and to lash out at her younger brother. Laura, her mother, is at her wit's end. She is getting no sleep either. First I tried standard pediatric sleep interventions, then a little hypnotic, but it was getting worse, not better. Finally, 3 weeks ago, Laura was pleading for me to find a way to help her daughter. I decided she may have an anxiety and depressive disorder, and started her on a low dose of an antidepressant, Zoloft. I explained, a few children may become more agitated, we need to watch closely and stop the medication with the earliest sign that it may be making her worse. I hoped for the best, and sent her off to a child psychiatrist.

Yesterday, Madeleine returned. I opened the door and Madeleine shot me a huge smile. Laura said Madeleine is back to her old self. She is sleeping through the night, her sleep cycle is restored, and she is back to her old self during the day. The psychiatrist concurred with the medication. And now Madeleine has the most infectious, beautiful laugh I can ever remember hearing. She will stay on that little, miraculous dose of antidepressant for now. Drugs may be overused in children, but I hope they will never be completely taken away from us. Children like Madeleine need them.

Quiquil's daughter

Like most natives of the remote province of Huehuetenango in Guatemala, Eufemia is surprised that I am familiar with her home territory. I spent a short period of time working in a clinic in Barillas, where the road stops as it winds through the mountains north of the capital, Huehuetenango. There, you are as likely to hear K'hanjobal on the street, an ancient Mayan language, as Spanish. Now, for whatever reason, there are many Guatemalans from this region in our town. They work the lowest of the low jobs. Eufemia is a seamstress. She had 5 children at home with the help of a midwife in her home town of Quiquil, the site of a 1981 massacre of 32 people. Humble and reserved, she labors to give her children a chance of doing better than she. Today I see Eufemia for a routine physical and advise her on exercise...which must seem strangely foreign to a person who grew up with physical labor from daybreak until dusk.

Zuleyma's painting

I've been trying to slow down Zuleyma's weight gain, almost from the day I delivered her, 15 years ago. Now, at 15, she weighs 258 pounds, and both of her parents weigh close to 300 pounds. Even at her first newborn visit at 2 weeks of age, she was already off the charts for weight. At first I thought it was overfeeding, then lack of appropriate exercise, or fattening school lunches, and more recently I've come to believe it's a genetic force I can't beat. At least, I do not want to be so frustrated with her weight and my own personal feeling of powerlessness that I stop seeing Zuleyma as a girl, a unique person who is trying to find her way in this world. I am not willing to give up the unique relationship I have with her, caring for her from conception until adulthood. It's too easy to dehumanize people with obesity or with any other problem and look at them only as their problem. When I walk by Zuleyma's 2nd grade painting in the hallway, I see the river winding through the complex topography of our city and I smile.

Judy's cat is dying

Judy's cat is dying of cancer. At age 76 she doesn't think she can survive the loss of Precious. After all, she almost died of heartache after her husband, Ted, died 9 years ago. Somehow she survived then, on a diet of donuts, coffee, and a steady chain of Kool cigarettes. But after 9 years her self abuse finally caught up to her. On November 3rd she began to feel unwell. She called her next door neighbor, who happened to be a cardiologist, who came right over and was immediately suspicious of a heart attack. Soon after the EMT's arrived her heart went into a series of arrhythmias (electrical short circuits) that reduced her blood pressure to dangerously low levels. She received shocks 3 times in the ambulance and another 9 time in the ER and intensive care. Somehow she survived, though she lost a large chunk of heart muscle in the process --- a massive heart attack. But today it is not her own survival that concerns her, it is her cat, the only being in her life that gives her companionship and someone to share an otherwise lonely place in this world. Could she have an antidepressant to help her get through this? That's not problem. I know she will not go to a counselor, but she will take an antidepressant, and perhaps stay in a little closer touch with me. Pets are so important to the emotional and even physical health of widows who live an otherwise isolated life.

Get up and walk, Ignacio

Ignacio appeared to be in pain as he was pushed by wheelchair into Room 16. Pulling his pantleg up it was clear why. His right knee was about twice the normal size, and tender to touch. Apparently he had been in the urgent care center over the weekend and had fluid aspirated from the knee to look for bacteria and crystals. Because he had had an episode of gout before, gout was the number one likelihood as the cause. But two things bothered me, first that he had no crystals in the fluid, and second, Ignacio is not a completely straight shooter. By that I mean he has a long history of drug addiction, and that means he could have a septic joint, infected by bacteria that happen to get in the body by dirty needles and then take up residence on the heart valves. Also, I have to think about gonorrhea, which can also migrate from the genital area to the knee if not treated. Fortunately, fluid had been sent for the proper analysis on Saturday and there was no sign of infection. I prepared his knee with iodine and then stuck a long needle into the center of his knee, aiming just under the kneecap. Within 5 minutes the local anesthetic was beginning to take effect and his complaints had settled down. He was able to get up and walk out of the room. There's not much more dramatically effective than an injection of steroid and lidocaine for someone suffering from an attack of gout. Next week we'll try to address the alcohol abuse and heavy seafood that probably triggered the attack.

Marina's back

I came in late to work on a letter for Marina tonight. She can't work because of a back injury, and like so many immigrants, an injury at work is often ignored by employers. It seems to be the attitude that if you don't speak English well, don't expect any rights as a worker. If you get hurt working you will not have the rights that Americans have for workman's compensation or disability insurance. We can find someone to replace you tomorrow. And yet, immigrants work in the most dangerous jobs, and the injuries can be ordinary -- or horrendous. That's a story for another day....

Jazlyn's long fingers

Last week I was surprised to see Magali again. I hadn't seen her in a couple of years, since she almost bled to death trying to carry a pregnancy that she should never have attempted. She was so angry at me for telling her the truth, that a pregnancy could kill her, so she went ahead with her boyfriend and conceived anyway. As a Mexican woman, the thought of not being able to offer a child means being cut off and thrown away by most men. So she went ahead, got pregnant, and as her aorta began to rip apart she was forced to have an emergency C-section and dangerous replacement of a large section of her aorta. Somehow, I don't know how, it's a miracle, she and her baby survived.

She hadn't talked to me for a long time, but a couple weeks before she told me she was concerned about her daughter Jazlyn, now age 5. Could Jazlyn have the same Marfan's Syndrome as her mother? We agreed that she would bring her in.

Mexican children are taught to be polite to their elders, and so any child, age 18 months and above will offer a formal handshake. The day Jazlyn came in, I walked into the room, she held out her hand, and when I took her hand in mine, I recognized the same long spindly and flexible fingers as her mother, the same fingers that indicated she probably has Marfan's syndrome too. Medical books call this "arachnodactyly", or spider-like fingers. Of course I needed to go over her exam more formally. Yes, she was way above normal height for her age. Yes her fingers and wrists had almost rubber-like flexibility. We talked about the genetics of Marfan's syndrome that her daughter had a50% chance of having the disease, and that we needed to start monitoring Jazlyn's heart and blood vessels. I hope Jazlyn will not have to make the same choice as her mother, between remaining childless and loveless or risk of death from attempting pregnancy.

Where to go with weakness?

Greg is a handsome man in his early 30's who looks worried. The note on the chart says he is in for recheck of urinary tract infection/fever. But as often is the case, the supposed reason for visiting falls far from the mark of what is on Greg's mind this morning. It starts fairly simply-- he had a urinary tract infection a couple of weeks ago, was treated with an antibiotic, but now has some mild diarrhea and fever again. As I go over the history, the first thing that is puzzling is that he had a urinary tract infection. Men are not supposed to have them. It could indicate an underlying condition of some type. Greg hesitates, and then says, he has actually been having changes in his urination since last summer, when he started having to get up at night numerous times to urinate, and since then his urination has never completely normalized. Asked about his fever, he states that he actually feels weak. Weakness is often interpreted differently by different persons, so I ask him about the weakness in different ways, finally concluding that he has had generalized weakness of his muscles, that worsened with the onset of his infection two weeks ago, and now is worsening again. Weakness is a worrisome symptom if true in a strict sense, and not just merely fatigue or feverishness. Prompted by this detail, I ask him more about his recent history. He's actually had an episode of double vision last November that lasted for a couple of months and required the use of special lenses. Together these symptoms raise a troubing possibility: that he has been struck by atleast 2 epsiodes of loss at different times and locations in his nervous system. One in the part of his brain controlling the coordination of his eye muscles, the other in his spinal cord, controlling the function of his bladder and leading to the current urinary tract infection. Multiple sclerosis causes this sort of pattern, and Greg's cousin has been diagnosed with MS as well. Greg seems relieved that someone is starting to put together his variety of symptoms, and was actually very worried about what was happening to him. He will have an MRI of his brain next week. It is never easy to broach the possibility of a disabling, chronic illness, but never as bad as the fear and loneliness of falling through the cracks and knowing that something is terribly wrong.