I Saw This in a Book Once...

The patient sits down on the exam table and says he has allergies. My eyes glaze over. This is the millionth inmate with allergies this week. I start to go into my allergy work-up, which includes asking if he's tried the OTC meds available in the commissary. If not I can't prescribe anything yet. And if he says he can't afford to buy them then I have to check his account to see if he's truly "indigent" or if he's blown all his money on soda pop and lollipops.

He interrupts to say that he also has a rash on his neck and groin. He turns to show me his neck. Then pulls down his pants to reveal a similar rash. I see darkly pigmented skin. No pustules, no erythema.

Without saying a word I reach over to the bookshelf and flip open to a page showing exactly the same thing. My guy could be the same guy in the book. Young overweight Hispanic dude. Confidence radiating, I explain to him it looks like acanthosis nigricans, a common skin finding in overweight diabetics. I ask if he has diabetes, although I smugly already know the answer.

"No! I told them I don't have no problems with diabetes or high blood pressure. I exercise three days a week," he states emphatically.

I check his chart. He's been prescribed Metformin, an oral medication for diabetes, and Lisinopril to help lower blood pressure and protect his kidneys. Not feeling quite so confident, I ask if he's been taking the meds.

"Never started them," he says. "I don't have diabetes."

I pull up some recent labs. Blood glucose 234. Too high. I explain that the number should be closer to 100, and that he really should start taking the medication as prescribed. He disagrees and we go back and forth. He exercises, and says that's enough. I falter. I go ahead and check his blood pressure, which is pretty good, and look in his eyes, ears, and nose. I try again and he looks pissed. He just wants his allergy shot (which I'm not about to give him and I later found out raises your blood sugar), and he wants to go.

I point to the book again, the lab tests, the doctor's previous note, and say bluntly that the allergies won't kill him, but this could. Give it a few years and he won't be feeling as well as he is now. This requires more than exercise. He agrees to another blood test. I order a glucose level plus a glycolated hemoglobin, which will give a more accurate picture of his blood sugars over the last three months. I throw in another couple of blood tests and finally give him something he wants: some intra-nasal steroids for his allergies. Then he's gone.

I probably could have handled it better, but he wasn't in the mood for listening to anything, so maybe it didn't matter what I said. In his mind, he walked in with allergies and left with diabetes. Probably not the way he imagined it would turn out.

Not the way I imagined it either.