Think Like a Doctor: Packing on the Pounds

This post was originally published on this site

The Challenge: Can you figure out why a 59-year-old woman keeps gaining weight?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to try their hand at solving a medical mystery. Below you will find the story of a woman who has been gaining weight despite years of work to lose it. Was this, as the patient worried, a result of menopause, or was there something else going on? She was frustrated and aggravated, but should she be worried?

Below I provide much of the information available to the doctor who made the diagnosis. Regular readers may assume that this, like so many of my cases, is the zebra. But is it? The first reader to offer the correct diagnosis, along with the missing piece of data that helped the doctor get there, will receive a signed copy of my book, “Every Patient Tells a Story,” and the satisfaction of solving a real life case.

The Patient’s Story

“I just can’t seem to lose weight,” the 59-year-old woman said quietly. She’d done everything, she told the young doctor. Weight Watchers. Exercise. She drank more water. She ate more vegetables. She tried eating less fat, then only “good” fat. She kept food diaries, downloaded calorie counters. She’d done it all.

And not only was she not losing weight, these past few years she just kept on gaining. Despite all of her hard work, she’d put on maybe 50 pounds in the past year.

More Than Skin Deep?

She decided to go to Dr. Donald Smith, an endocrinologist at Mount Sinai Hospital in New York. She’d seen the doctor years earlier in a documentary on weight loss surgery on TV. The fact that he was an endocrinologist made him a doubly good choice for her because she worried that the real cause of her weight gain was hormonal.

She first met with the doctor in training who was working with Dr. Smith as part of her endocrinology fellowship. She’d never been skinny, she told the young doctor. But she’d never been heavy like this before, either. She was 5-foot-4, and throughout her 20s and 30s she’d weighed 170 to 180 pounds. It was a comfortable weight for her, easy to maintain. Then, in her mid-40s, weight maintenance was no longer easy and the pounds started to accumulate, slowly at first, then rapidly.

She was considering bariatric surgery, but first she wanted to know, was this just a consequence of menopause? She had thyroid disease and had been on the same dose of medication for years. Could something have happened to her body so that the drug was no longer working for her?

The Patient’s History

Did she have any of the symptoms associated with a low thyroid hormone level, the young doctor queried? Fatigue? Oh yes, these days she always seemed to be tired. Had she seen any changes in her hair or skin? No. Any constipation? No. Do you get cold more easily these days? Never. Indeed, these days she usually felt hot and sweaty.

Any other medical problems, the doctor asked?

Oh sure, she replied promptly. She had high blood pressure and high cholesterol — both well controlled with medications. She also had obstructive sleep apnea, a disorder in which the trachea, the breathing tube connecting the lungs with the nose and mouth, collapses during sleep, causing the sufferer to stop breathing and awaken many times throughout the night. But she had a machine that helped keep her trachea open and used it every night.

In addition, she had low back pain from a place where her spine had become narrow. She had knee pain and carpal tunnel syndrome. She didn’t smoke or drink and had worked as a nurse until the pain in her back, legs and hands forced her to retire early.

Big, Bigger, Biggest

After a quick examination, the young doctor stepped out of the exam room. She returned a few minutes later with Dr. Smith. He looked to be in his mid-60s and had a kind face and friendly smile, just as the patient recalled from the TV show she’d seen him on. The young doctor briefly summarized what she and the patient had talked about. When she finished, Dr. Smith turned to the patient and asked if there was anything she’d like to add.

She thought for a moment. All she could say, really, was that she didn’t understand why she was getting so much bigger. She was gaining weight, but it wasn’t just that. Her legs and feet were huge. She used to have nice ankles, but now you could hardly see them. Her regular doctor, a cardiologist, gave her a diuretic, but it really hadn’t done a thing, she told him.

Not Just the Legs

Dr. Smith leaned over to look at her lower legs a little more closely. They were quite swollen. And yet when he pressed his thumb against the skin there was none of the give he would have expected in such bloated-looking limbs. Usually with swelling from edema, which occurs when extra fluid leaks from the blood vessels into the soft tissues, any firm pressure will leave a deep impression.

The presence of apparent engorgement that doesn’t compress suggested that the patient may have a condition called lymphedema, an accumulation of fluid rich in white blood cells that is normally collected from the tissues and then drained through the tiny vessels of the lymph system. If these vessels somehow become blocked, the fluid backs up and the skin around them becomes thick, inflamed and eventually scarred.

It’s not just my legs, the woman added. It was everything. Maybe this sounded crazy, she told him, but she didn’t feel like she was living in her own body. She’d explained this to many doctors. They’d just encouraged her to lose weight.

Over the years, the patient had been to many doctors. You can review some of the lab results her various doctors had ordered in the two years before she’d come to see Dr. Smith.

Review the patient’s lab results from 2013 here.

2013 Labs

The patient’s labs.

Review the patient’s lab results from 2015 here.

2015 Labs

The patient’s labs.

You can also review the note from her last visit to her regular doctor, a cardiologist, here.

Cardiology Note

The patient’s visit with a cardiologist.

Solving the Mystery

There was one more piece of data that led Dr. Smith — eventually — to the answer. Can you figure out what that missing piece of information might be? And the diagnosis it led to?

Post your answers in the comments section. The first reader to figure out both parts of the puzzle will get a signed copy of my book and that special satisfaction of solving a mystery that my readers know so well.

I’ll post the answer tomorrow.

Rules and Regulations: Post your questions and diagnosis in the comments section below. The correct answer will appear Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.