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Slow Moving Diagnosis: Part 1 – Consult with primary care

Dr. Green was quick to smile, his easy grin squatting on his wide, fleshy face. “What brings you in today?”

I looked at the unevenly posted flyers on the wall, considered the BMI chart that showed both Robert and me slipping from the healthy green to the overweight blue and tried to match Dr. Green’s friendly, open demeanor. “Robert has not been acting himself lately. His judgment has been off. We went to Friedman’s recently, and he didn’t speak up when he knew we were not buying everything we needed for a project we were working on. It’s like he wasn’t really there with me.”

Dr. Green

Dr. Green had been Robert’s primary care physician for over ten years. Robert respected him; I’d heard only good things. He nodded at me and asked Robert if he felt the same. He did not. Dr. Green asked Robert a few probing questions about where we were, his address, what time of year it was, and who our president was. He answered all the questions correctly. (Even confirming that Trump was a “jerk” and shouldn’t be president.) He looked in Robert’s ears and listened to his heart and chest.

Still, I could feel Dr. Green watching me, could see him periodically give me a knowing look. With his final turn back to Robert his posture shifted, he became more tender somehow. He gently patted Robert on the back like he might someone who was feeble. With those unspoken signals, he confirmed that something was off. A chill enveloped me in the exam room. I felt like I was with a six-year-old in the pediatrician’s office. I needed to speak to the physician alone because I couldn’t possibly hear what needed saying in front of the child. 

I’d spent years building resentments and anger toward my husband who I felt was no longer adequate to the job. I’d been operating from a very ugly place. Suddenly the mask of righteousness I’d cultivated as a victim of Robert’s lack of focus and responsiveness just slipped away. I was sitting with the man I loved who was failing. I knew it. 

Tests ordered

“I’d like you to get some tests today: a urinalysis and a CT scan. We can’t do the CT scan here. You’ll have to go down to San Rafael. You can stop at the lab on your way out to drop off a urine sample and I’ll let the Emergency Department in San Rafael know you are coming in.”

Robert left his sample at the lab and we hopped in the car to drive the 30 minutes to the hospital for Robert’s CT scan. I was numb. What were we going to do? I was already working as hard as I could. How would we cope?

The ER doctor confirmed that Robert’s urinalysis had come back clean. In older adults, an untreated UTI can cause delirium, resulting in a sharp decline in mental abilities that can mimic dementia, but that was not Robert’s problem. The CT scan was completed. Test results would be read quickly and we’d hear back from Dr. Green by the end of the day. 

The bad news begins

We didn’t even make it home before Dr. Green called. I took his call in the car.

“Robert has had a stroke. There is a ‘hole’ in his right temporal lobe that matches the signature damage of a stroke.” He paused to let this sink in. “Did you notice any symptoms of stroke? Has Robert ever had trouble moving one side of his body? Any muscle weakness? Has he had trouble speaking?”

No. No. No. No. We didn’t know a stroke had occurred.

Dr. Green ordered an immediate start to a prescription of statins which are normally used to control cholesterol (Robert’s was last measured at a healthy 147). They have some pronounced, common side effects, but they can also prevent cardiovascular disease recurrence after a stroke. An ischemic stroke occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients. Brain cells begin to die within minutes. Robert’s (apparent) stroke killed off some of the brain cells in his right temporal lobe.

My stomach dropped. I stared ahead through the windshield at the hills greening up with the first rains of the season and marveled that there was life springing up while Robert’s health was suddenly precarious. My trepidation was not misplaced. This was just the first step in a long diagnostic process.

Dr. Green referred us to Neurology.

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