|Photo by Anthony Papagiannis.
Unless we are in pediatrics, we start in clinical practice with our patients tending to be in the age range of our parents, or even older. Increasingly, as the grey in our temples is promoted to silver, their mean age gets closer to ours, and the percentage of younger patients keeps rising. These younger patients have their own health problems, some commonplace and benign, some more unusual and even ominous.
Recently, in a single clinic session I saw two young women, one right after the other. Same age, around thirty, with attractive looks as much as the mandatory face masks allowed me to judge, and healthy in appearance. Their histories spoke otherwise.
One lived and worked abroad. A few months back she had had Covid-19, which meant three weeks of isolation at home before she was again able to fend for herself. She had since improved considerably, but had persistent fatigue, and had never been checked by a doctor—the country she lived in was very frugal in testing and treating virus cases, despite its advanced and free-for-all healthcare system. There was nothing physically wrong with her, but she had a deficient spirometry. She had never smoked, and used to be athletic and quite fit. I gave her some inhaled medicine, and the reassurance that time would restore her back to full function. It was the first post-Covid case I had seen, but I was reminded that we still do not know enough about possible long-term pulmonary sequelae in patients recovering from the virus.
The second lady presented an altogether different problem. Previously quite well, she started getting muscle twitching and some weakness in her hands, which got worse with time. She had a mild hesitance in her gait, and a slightly nasal voice. Her diagnostic workup was ongoing, and the neurologist had requested a spirometry. She had no abnormal physical findings, could lie flat without getting breathless, and had normal oxygen saturation. However her spirometry showed mild restriction, and she had some difficulty swallowing, with occasional choking episodes. When she had left I rang up the neurologist, an old friend.
“Looks like an unusual form of motor neuron disease,” was his grim answer, “quite atypical, and we are still investigating her.” This tallied with my gross impression of something unpleasant brewing up. In my mind I traced her future course over the next several months: progressive motor weakness, inability to swallow or lie down, increasing choking and aspiration, with the eventual need for gastrostomy, tracheostomy, and noninvasive mechanical ventilation, until the difficult end-stage with its tough ethical dilemmas. With a sinking feeling in my heart, I thought that some people seem to draw quite short straws in the lottery of life.
Beauty is indeed skin deep, and tells us virtually nothing about a person’s inner world, their troubles, physical and mental, and the particular burden they carry in life. The truth usually lies below the surface. It is our sad duty as physicians to part the pretty veil of normality and bring to light hidden and often unpleasant realities.
ANTHONY PAPAGIANNIS, MD, MRCP(UK), DipPallMed, FCCP, is a practicing pulmonologist in Thessaloniki, Greece. He graduated from the Aristotle University of Thessaloniki Medical School. He trained in Internal Medicine in Greece and subsequently in the United Kingdom. He also holds a postgraduate Diploma in Palliative Medicine from the University of Cardiff. He is a postgraduate instructor in palliative medicine in the University of Thessaly, Larissa, and edits the journal of the Thessaloniki Medical Association.