"when we try to pick out anything by itself, we find that it is hitched to everything else in the universe" - j.muir
May 14, 2011
you are beautiful and have so much to offer the world
today I met Natalie*, a 18 year old woman who just had her first baby this winter. I wasn't even supposed to meet her - but my preceptor's last appointment didn't show up, so I asked one of the nurse practitioners if I could work with her for the last hour of the morning. she sent me into Natalie's room saying, this should be an easy one. Come out and get me in 10 minutes when you're done.
she's wearing a sundress, it stretches gently over her full abdomen. she still has the pregnancy glow, even though she's 3 months postpartum, or maybe that's just what it looks like to be 18. she kicks off her flipflops as we speak. she doesn't look sick. she speaks softly, but directly, and asks me if she has hypothyroidism.
hypothyroidism means not enough of the thyroid hormone (T3 or T4), which is responsible for regulating all sorts of important things, like your metabolism and heart rate.
her whole family has it, she tells me, and she thinks she has it too and that's why she can't lose weight.
"okay, we can check that," I say, "but I have to ask you some questions too, is that okay?"
she says sure and we talk about how she has incredibly heavy periods, has always battled with her weight (she had an eating disorder in her early teens, and since then her BMI has been consistently above 30), she gets cold when other people are hot, her hair falls out in the shower, and she has been depressed most of her life.
all of these are the symptoms of hypothyroidism. so I do a physical exam to check her for the signs of hypothyroidism: she has an enlarged thyroid, dry skin, marks of hair loss on her eyebrows and head, her deep tendon reflexes are decreased (though I can't tell if this is just because I still feel badly hitting people's knees very hard). yup, the signs are all there.
now all that's left is to run the lab test for thyroid disease, a TSH level. But first, for some reason, I decide I should also screen her for diabetes - because if she's getting lab tests, and her family has a history of obesity (and diabetes), we should at least have a baseline. So I ask her if, not counting when she was pregnant, she has increased frequency of urination. She says yes, and in fact, she wet the bed until she was in the 5th grade. Hm. Was there anything else that caused you to wet the bed that long (thinking, stupidly, wow, that's really young to have diabetes). "Oh yeah," she says, "I was sexually abused from the age of 4 until the age of 11 - well, really 14. I think I was anxious." <> "and I've never told any doctor that before".
Before I can say, well...you still haven't, because I'm not actually a doctor yet...
I bite my tongue and think: okay, she has a history of depression and anxiety, obesity, migraines, bedwetting until 4th grade, eating disorder in early teens that became dramatic obesity in her later teens, yup - that does make sense. why did I not ask about psychiatric issues at all? but by this time we were getting way past the end of our visit. But I want to ask her if she sees a therapist (yup, weekly) okay, good. so she's told someone else. and if she feels safe in her current relationship (yes, definitely, that's all in the past). Okay, so no immediate threat. We talk a little more about her support network and home life. I make a note to talk to her PCP about this before giving her the lab order forms and sending her on her way.
My mind is not at ease about this and thoughts run through my mind:
Was that good medicine? Did she even feel good about that visit? Is helping with her thyroid my role right now? Or is it bigger? How can I have been learning so much about violence against women and not have asked her? Especially with her history of medical problems?
After seeing a few more patients, I break for lunch and run out to grab a salad - Natalie is in the hallway with her fiance and their new baby. As I walk by she smiles shyly and says to her baby, "hey honey, want to meet Mommy's doctor?" and brings her baby over to me. I try to think, oh dear, I am not your doctor - but instead I take the baby and look at her and say, "oh, you must be so proud. she's a beautiful baby."
*obviously not her real name,
some information has also been changed for confidentiality