When Keeping a Straight Face Causes Actual Pain
Today I saw a 67-year-old smoker with hypertension and diabetes who only comes to the office for acute problems. The last visit was three years ago for a sore throat; his blood pressure was 180/80. He promised to come back in two weeks to address his other health issues. Today (three years later) he comes in worried about a week of diarrhea (that's getting better.) His blood pressure is now 190/90 and his pulse is 130, though he's afebrile and in no distress whatsoever.
His exam is basically normal, though I can easily feel his aorta (he's skinny.) I want to do an EKG, a blood test (worrying about kidney function, diabetes control and anemia, among other things,) get an ultrasound to rule out an abdominal aortic aneurysm, give him a dT booster and suggest a colonoscopy. All he lets me do is draw the blood. I want to give him samples of Toprol 25 XL but all I have are 50's; it takes twenty minutes of explanation to get across that I want him to take half a pill every morning, and that I need him to come back in two weeks.
This is what I say to him (many times; he will not stop talking, asking the same questions over and over):
If you don't do what I say and come back to take care of these things, you are probably to have a stroke (or a heart attack) within five years, and probably less.I wish to Gd I was kidding as I report his response (no sarcasm; not trying to be funny; deadly serious; a statement, not really a question):
"You're levelling with me, aren't you."
Disclosure (sort of): yes, there are intellectual issues somewhat beyond not being the sharpest tool in the shed. But still...geez!