Thorough

A Thorough Physician

My nearly ninety year-old mother was failing.  She had always been more active than her age-defined cohort, she had cooked, quilted, hooked rugs and was a star personality in the local Presbyterian Church.  She was proud of herself:  her skills, her know-how and her energy.  Now she had become too tired, too fatigued to enjoy these skills.  

Although in part we could attribute her condition to advancing age, her internist, an excellent physician, took our observations earnestly; he was by all standards an earnest man.  She may have not complained to him, but I did, and years before I had been his Chief of Medicine and he my Chief Medical Resident (CMR). Our CMR’s were chosen from among their peers to assist the teaching faculty.  Nearly all CMR’s have been luminary physicians both on the wards and in the clinic.

The physical examination, and the routine focused laboratory examinations were normal:  no anemia, kidney failure, diabetes nor an occult cancer, nor evidence for polymyalgia rheumatica.  The thyroid stimulating hormone level was within the normal range. After this thorough inquiry and examination, he had no explanation for her failure. He was earnestly puzzled

Months passed and repeated evaluations showed no change.  Then he retired and a new physician took his place.  She as he before him had been one of our CMR’s.  

While assisting with the transition of Mother’s care, I told her of the downhill trajectory.  Before Mom was see in her clinic, her new physician had reviewed the medical records, and she found no new data, but she reinterpreted existing data:  although the thyroid stimulating hormone (TSH) level had always measured within the normal range, in the last years it had fallen from a high normal to a low normal level.  

TSH, which comes from the pituitary, the master gland, is lowered by thyroid hormone (TH) which comes from the thyroid gland, and in normal events they act in feedback to each other to balance the levels, much like a teeter-totter.  

Using a graphing function embedded within our new electronic medical record (EMR), she tracked a dramatic steady linear decline in Mother’s TSH.  Her observation that the TSH had persistently fallen meant that the TH had probably risen during that same time to a higher level. TH levels are not routinely measured unless the TSH is in an abnormal range.   In response to the trend of the falling TSH, she measured the TH and it was high.  Mom’s thyroid was overriding the low TSH.  The thyroid gland had become an autonomous force not responding to the signal from the master gland that enough was enough.  

My mother had hyperthyroidism, and additional testing and consultation with an endocrinologist, a thyroid expert, confirmed this.

Mother’s condition is known as Apathetic Hyperthyroidism.  It is unusual, and when it happens it is almost always in old people.  The usual presentation of hyperthyroidism has to do with the TH’s stimulation of the sympathetic nervous system, best know as for the production and release of epinephrine.  This explains why hyperthyroidism usually presents with the tremors of sweaty hands, sleeplessness, and overactive reflexes.  It resembles a case of continuous performance anxiety.   In old people, however, the sympathetic nervous system has usually, to a great degree, withered away, and epinephrine is not abundantly released.  Old patients therefore don’t present with the usual outward signs of the condition, but with manifestations common of old age:  loss of weight, loss of energy and apathy. 

My mother’s highest praise for a doctor was that they had been thorough.  She seemed to reserve this adjective exclusively for physicians.  Both of her physicians had met her approval as thorough, and they were.  Her second physician just happened to synthesize a fresh look at old data using a new tool, the EMR.