Gettysburg Medical Center
 The Clinical View
 by P.E. Hoffsten, MD
 14 June 2006

“WHAT DID I SAY?”

             A gentleman came to the clinic for a check up several months ago.  He said that he was feeling well and really had no medical complaints.  I told him that usually when a person comes to the clinic for a checkup, something has gotten their attention.  It might be an ache or some abnormality on the skin or an article in the newspaper or something on TV that they saw and should be checked out. This is especially true regarding those infrequent clinic visits made by South Dakota males.  He laughed and said his wife read some of my columns in the newspaper.  She was constantly telling him that he should take care of his cholesterol, take care of his blood pressure, keep his weight down, exercise, not drink too much, quite smoking, etc. etc. etc.  He said that he just really wanted to talk to me.  He never read the articles his wife read but he wanted a first hand account of what they said in regard to his life.  He was a 62 year old ready to retire executive who took no medications at all.  His father had passed away from a heart attack when the father was 66 years old and one brother, age 52, had already had bypass surgery.  There was no history of cancer in the family.  The gentleman did not know his blood pressure or his cholesterol.

            So I asked him what he was hoping for.  He blithely said that he was hoping for a long and happy life.  He didn’t want to get Alzheimer’s disease and he didn’t want to be dependent on others for his care as he aged.  He was very active and wanted to stay that way.  So here is what I said:

            1.  I checked his blood pressure which was a 145/95.  I told him that this was probably the most important point to address.  His blood pressure should be 120/80 or less.  I told him that it was unlikely that this could be done without a medication but that there were medications available which would not have side effects and would control his blood pressure.  I said that his risk of heart attack, stroke, disability and Alzheimer’s disease were all markedly more likely if he did not control his blood pressure.

            2.  His cholesterol was determined and found to be total cholesterol of 280 mg% with bad cholesterol of 140 mg%.  I told him that the bad cholesterol in his blood should be less than 70 mg% and that there was no thought that this could be done without a medication.  If he did not get his cholesterol down, the risk of stroke, and heart attack with the associated disability was markedly more than if he did control his cholesterol.

            3.  I inquired about his smoking history and he indicated that he had been trying to discontinue it for years.  To this time, it had never been achieved.  I pointed out that if he smokes cigarettes there is exactly a 50/50 chance that cigarette smoking will be the cause of his death.  Duty in Iraq, sky diving, playing chicken on the freeway and peaking under the Lone Ranger’s mask are no way as dangerous as smoking.  The risk of heart attack, stroke, cancer, Alzheimer’s disease and emphysema are all directly related to smoking cigarettes.  I pointed out that if he really wanted to be independent as he aged, he needed to stop smoking.

            4.  His blood sugar was checked and fortunately, was not abnormal.  There did not need to be any type of intervention in regard to his blood sugar.  Diabetes is the 5^th leading cause of death in the United States and the fastest growing cause.  The disability that comes from diabetic blindness, loss of feet, and kidney disease is staggering and avoidance of diabetes or control of the condition once it occurs is a pivotal part of care.

            5.  Osteoporosis is a very common cause of disability in women but also a frequent cause of disability in men.  Managing bone mineral density and avoidance of the Dowager hump that comes from collapse of vertebrae in the back is pivotal in avoiding disability and broken hips.  We checked his bone mineral density and it was normal.  He was instructed that 1200 mg of calcium a day intake along with 800 units of Vitamin D was important in long term maintenance of bone mineral density.

            6.  Staying physically active is a critical part of long term maintenance of health.  Granted people can’t play football when they are 62, milder exercise such as walking is encouraged within capability.  The national recommendation for walking is 3 miles per day every day.  If one cannot do this, they should strive for what they can do while maintaining their well-being.  But daily walking is an important part of long term care.

            7.  Cancer surveillance is associated with longevity for two major cancers.  Specifically, mortality from breast cancer in women is cut in half by having mammograms done on an annual basis.   Secondly, cancer of the colon is completely avoided by having colonic exams done on a periodic basis.  Cancer of the colon is the third leading cause of cancer death in the United States and a completely preventable disease when surveillance is done appropriately.  As undignified as it is, this gentleman did agree to proceed with a colon exam and fortunately it was normal.

            8.  Alcohol excess is a common cause of Alzheimer’s disease in our society.  Those that drink more than 4 alcoholic beverages per day over an extended period of time run a very high risk of developing Alzheimer’s disease.  The more the person drinks, the more likely permanent brain damage will occur on a slow steady basis.  Two drinks a day or less is associated with longevity.  More than that is clearly bad.

            9.  It used to be said that the most dangerous situation in the United States was a 15-25 year old male behind the wheel of a car.  With the aging of our population, it is now known that the most dangerous situation in the United States is a man over age 50 on a ladder.  Accidents and injuries secondary to injudicious activity are a common cause of morbidity and mortality in our society.  Accident avoidance is an important part of long term care.

            10.  The most underrated, unrecognized aspect of long term general health is adequate rest and sleep.  Snoring is a source of jokes but an even bigger source of sleep apnea, poor quality of sleep and heart disease.  The healthcare professionals at your local clinics can work with sleep problems as they develop.

            So those are the 10 things that I had to say to him.  I must say that he listened.  He is now on a blood pressure pill and blood pressure is down in the normal range.  He is on a cholesterol pill and his bad cholesterol is below 70 mg%.  He did get a colonoscopy done and that was normal.  His weight is not excessive, he is not diabetic and his wife acknowledges that he doesn’t snore.  His cigarette habit has been cut back but not out.  I told him that the average number of attempts before a permanent success was seven.  He said he would continue to work on the problem.  I thanked him for coming in to help save his live and thanked his wife for caring about him.  He acknowledged that the visits and medications were not nearly as bad as he expected.