A Country Doctor Writes:

Fritz Daum kept bringing in erratic and disappointing blood pressure logs, always too high but never the same. His office readings were the same way. He was clearly worried and also quite probably disappointed in my therapeutic skills; most medications I prescribed did little for his blood pressure control, and many had unpleasant side effects.

We got access to continuous blood pressure monitoring two years ago, but I hadn’t ordered it before. I made Fritz my first patient to use it. The result was illuminating. The first and last two hours’ readings were high. In fact, the tracing started high and gradually normalized over a couple of hours, and the last two hours before the monitor was removed showed a steady rise in his blood pressure.

It seems Fritz gradually stopped thinking about his blood pressure, since the machine was doing it for him. Then, as he got ready to drive to the clinic to have the leads removed and the monitor disconnected, he probably started wondering what the recording would show.

So, now I know what he has: not white coat hypertension, but anticipatory hypertension. White coat hypertension has been re-evaluated and my medical school teaching disproven, see below, but what do we know about anticipatory hypertension?

I found a few articles about this. A 1996 article in Hypertension looked at blood pressure seated on an exercise bicycle just before starting a session, compared with at rest one week earlier. It showed that “men showing systolic responses greater than or equal to 30 mm Hg or diastolic responses greater than 15 mm Hg [had] nearly four times the risk of becoming hypertensive.”

A 2018 article in the Journal of Hypertension describes an anticipatory rise in blood pressure before self measurement “that remains present after multiple BP readings”.

I’m not sure whether anything needs to be done with Fritz, my frequent checker. My inclination is not to prescribe more medications, including for blood pressure anxiety, but to see where his office readings land if I can get him to stop checking his own blood pressure at home for a while.

A Country Doctor Reads: August 10, 2019 – High Blood Pressure is High Blood Pressure, No Matter Where or When

“There is confusion and disagreement about diet, or should we say FOOD CHOICES, when you have Type 2 Diabetes”, I admitted. “But I’ve done my reading. I have had my own experience losing weight giving up being a vegetarian. And I have over 40 years of experience with diabetic patients – and curing some.”

These numbers illustrate what happened 2016-2017 when a diabetic patient of mine took my Flex Fuel talk to heart and drastically cut the carbs in his diet. We did not change his medications during this time – it was all because of his food choices.

A Flex Fuel Man

The Scandinavian languages have long tried to resist the incorporation of foreign words. The Norwegians are perhaps more into that in our time, but Swedish medical terminology is a powerful, very old example of our provinsionalism. Even though words like diabetes and stroke are now used by lay people, the old Swedish terms are by no means obsolete.

What sometimes makes our terminology doubly amusing to a non-Swede is the fact that, in our language, multi-word expressions or descriptions are written with no space between the words. For example, May Day demonstration is förstamajdemonstration in Swedish and a female laundromat proprietor is called a tvättinrättningsföreståndarinna, and there are even longer words than that.

Here are some samples of local Swedish medical terminology:

BÄLTROS – “Belt rash”: Herpes Zoster or Shingles (The Greek word zōstēr means belt and the word shingles is said to be related to the word zoster.)

BUKSPOTTKÖRTELN – ”The Belly Spit gland”: Pancreas (Greek for “all flesh”.)

SKÖLDKÖRTELN – “The Shield Gland”: Thyroid, shaped like the shield of a knight in armor.

KROPPSPULSÅDERN – ”The Body Pulse Vessel”: Aorta.

LILLHJÄRNAN – ”The Little Brain”: Cerebellum.

RYGGRADEN – ”The Back Line”: Spine

HALSMANDLAR – “Throat Almonds”: Tonsils

HALSFLUSS – “Throat Flow (discharge)”: Tonsillitis

KÄRLKRAMP – ”(blood) Vessel Cramp”: Angina

HALSBRÄNNA – ”Throat Burn”: Acid Reflux

BARNFÖRLAMNING – ”Child Paralysis”: Poliomyelitis

GULSOT – ”Yellow Sickness”: Jaundice

LUNGSOT – ”Lung Sickness”: Tuberculosis

KRÄFTA – ”Crayfish” (the Latin word cancer means crab or creeping ulcer. The Swedes just used the existing Swedish word): Cancer

KÖRTELFEBER – ”Gland Fever”: Mononucleosis

SOCKERSJUKA – “Sugar Disease”: Diabetes

SLAGANFALL – “Strike Attack”: Stroke

BENSKÖRHET – ”Bone Brittleness”: Osteoporosis

PÅSSJUKA – ”Bag Disease”: Parotitis/Mumps

SJUVECKORSKLÅDA – ”Seven Week Itch”: Pityriasis Rosea

ENGELSKA SJUKAN – ”The English Disease”: Rickets/Osteomalacia

DANSSJUKA – ”Dance Disease”: Chorea

KALLBRAND – “Cold Fire”: Gangrene

BLINDTARMEN – ”The Blind Gut”: Appendix (which is a small, dead-end piece of gut)

GRÅ STARR – “Gray Stare”: Cataract (which can make the pupil look gray or cloudy)

GRÖN STARR – ”Green Stare”: Glaucoma (occasionally associated with a greenish instead of red appearance of the pupil when shining light into the eye)

That is exactly what I tell my overweight diabetic patients. I also say “There may be more vitamins in fruit than in most candy bars, but unless you’re out jogging and need a quick calorie burst, fruit will raise your blood sugar and make you gain weight.”

“If you feel you must have dessert, and are already in the habit of eating pie, then switching to fruit may be a first step in breaking your dessert habit”, is another blunt statement I might use.

We can thank our dietitians for perpetuating the catastrophic EAT MORE FRUIT myth. People with sedentary lifestyles who are already obese or diabetic should not be told to ADD anything, even healthy calories, to their diet. Because for them, any additional calories will cause harm.

Instead of saying what to eat MORE of, I help my patients know what to eat LESS of. Then we work on adding back, or substituting, the right kind of foods.

It is simple psychology: When explaining a two step process, start with the big idea, in this case what to eat less of. That way, if your listener tunes out after the first part, they’ll still be on a better track than they were on.

But if people stop listening after EAT MORE FRUIT, and miss the second part (what to eat less of), your advice will have the opposite effect of what you intended.

We live in a culture that somehow can’t deny itself anything. It is as if we are recovering from a big famine and the thought of being hungry for a few minutes or not having exactly what we want induces PTSD. Our growing impatience and insatiable desire for more food, more entertainment, more convenience is causing many of our era’s current challenges – from lifestyle diseases to the environmental disasters plaguing us right now.

Nelson Malloy had infrequent but bothersome spells when he felt drained for half a day or more. He just couldn’t put his finger on exactly how he felt. Neither he nor I knew in the beginning what his symptoms were all about. The usual fatigue related bloodwork came back normal. His pulse in the office was exactly 50. On a hunch, I suggested tapering his lowest strength tablet of metoprolol tartrate down to half a tablet twice a day and that seemed to have solved his problem. The medication had been started after a questionable non-ST elevation myocardial infarction a few years earlier. Encouraged, he stopped it altogether and instead ended up with two hours of palpitations, triggered by a stressful event, with a heart rate upwards of 150. I advised him to resume the half tablet regimen. He may need more testing if he gets palpitations again.

Ben Chasse stumped me before with his drowsiness and his various neck and head pains. Was he just hypoglycemic with a herniated disc in his neck and an unrelated ordinary cellulitis, or something more exotic? Now, after neck surgery and off most of his diabetes medications, could his reoccurring spells of fatigue and shortness of breath be related to suddenly high blood sugars? After all, he was not anemic, his chest CT, echocardiogram and stress test were all normal and his peak flow was the same as mine. Time will tell, now that he is starting to take care of his diabetes again.

Sometimes the broader view holds the answer. It helps to ask “what else is going on” or to do a review of systems that includes things we might not think have anything to do with the chief complaint. 

Wanda Starks, years ago, puzzled me with her recurrent episodes of mild confusion, nausea and ever so slight headaches. She seemed to have a migraine equivalent, but it took ten years of infrequent by-the-way mentions before I realized what ailed her.

As I wrote about Wanda’s case back in 2008:

When you get stuck in a diagnostic dilemma you have two ways of approaching the problem. You can dig deeper and meticulously go over all the tests that have been done so far, looking for anything that could have been missed. You can also do the opposite, step back, clear your mind and listen to the patient’s story all over again. It is a little bit like those pictures in psychology class; the more you stare at them, the less likely you are to see the hidden image. Sometimes if you squint, you can see it right away.

And in 2009, in a story about Mrs. Jarvis’ spells of nausea, I also wrote about starting over:

“I am stuck,” I said. She sighed as I continued: “I must be missing something in your story.” Then, in a moment of inspiration, I got up from my stool and walked over to the exam room door as she followed my movements with suspicion and disbelief in her eyes.

With one hand on the doorknob I turned toward her and explained what I was doing:

“Pretend I’m an amnesiac or that you never met me or told me what you are feeling. I need to hear your story again from the beginning and without interruptions.”

The punch line in that story was:

Five minutes later, without asking a single further question, I knew what to do.

There are many ways to get unstuck. We must be prepared to use all of them.