Annual general exam — prediabetes, hyperlipidemia, and knee osteoarthritis

DRMrs. Casas! Come in, come in. How is the garden doing this summer?

PTDoctor, the tomatoes are showing off. I brought a little bag for the front desk girls — don't worry, I washed them. The zucchini, on the other hand, I am at war with. You turn your back one day and it's the size of a baseball bat.

DRYou're single-handedly feeding this clinic. It's wonderful to see you. So today is your yearly check — the full once-over. How have you been feeling since last summer?

PTThanks be to God, mostly good. I keep busy. Five of us in the house now — my daughter and the grandchildren moved in with me last year, you remember. She works nights at the hospital laundry, so I run the mornings. Lunches, school drop-off, the whole circus.

DRThat's a full-time job in itself. Are you getting any time for yourself? Friends, church, neighbors?

PTAh. Less than I should. By the time the little ones are asleep, I am also asleep. My friend Rosa calls, but visiting — no, not so much anymore. My world got small, Doctor. Busy, but small.

DRI hear you, and I want to keep an eye on that — a busy house and a small world can still be a lonely combination. How is the knee treating you? The arthritis.

PTToday, quiet. Zero complaints, if you can believe it. Summer is my friend — it's the winter when it creaks like my kitchen door. When it acts up I take the naproxen, the little blue ones from the pharmacy, 220, one with breakfast, and that settles it. Some weeks I take none at all.

DRThat's exactly how I like to hear it used — as needed, with food. No stomach burning, no black stools, no swelling in the knee?

PTNo, no, and no. My stomach is made of old country material. Very durable.

DRAny chest pain, shortness of breath, palpitations?

PTNo. I walk to the market and back, fifteen minutes each way, no problem. Uphill on the way home, I will add, for the record.

DRNoted for the record. Any dizziness, headaches, changes in your vision, numbness?

PTNothing like that.

DRHow's your sleep? And your appetite?

PTI sleep like a stone until five, then the worrying shift begins. Lying there doing arithmetic — the bills, my daughter, my sister back home. Twenty minutes of nonsense, then I get up and make coffee and it goes away.

DRLet me ask the mood questions properly, I ask everyone. In the past two weeks, little interest or pleasure in things you usually enjoy?

PTNo, not at all. The garden alone keeps me in business.

DRFeeling down, depressed, or hopeless?

PTNo. Tired sometimes, but not sad-tired. Just tired-tired.

DRAnd the worry — nervous, anxious, on edge?

PTA few days, yes. The five a.m. arithmetic.

DRTrouble relaxing, or feeling something awful might happen?

PTOnce in a while. When my sister doesn't answer the phone for two days, my head writes a whole telenovela. Then she calls and it's cancelled.

DRThat puts your anxiety score at a five — mild territory. Worry that visits and leaves, like you say. If it ever starts staying — keeping you from sleep past those twenty minutes, or following you through the day — you tell me, yes?

PTYes, yes. I promise.

DRNow, a few questions I ask every patient every year, and I ask them privately because they matter. Is anyone in your life humiliating you, frightening you, hurting you, or forcing you in any way?

PTNo, Doctor. And I know why you ask me especially. That was my first husband, many years ago, another lifetime. He is long gone from my life. In my house now it is me, my daughter, and three noisy angels. I am safe. I promise you that.

DRThank you for answering it straight — I'll keep asking every year all the same, because that's the job.

PTAsk away. The answer will stay boring, God willing.

DRAny cigarettes? I know the answer, but for the record.

PTHa! Two years of smoking when I was a teenager, to look interesting. It didn't work, so I quit. That was almost fifty years ago.

DRLongest-standing quit in my whole panel. Alcohol? Any drugs, marijuana, pills beyond what we know about?

PTA little cup of wine at Christmas. Otherwise no, nothing, never.

DRThat drug screen is a zero, as always. Now — medications. The list says only the naproxen, the 220 milligram tablets, as needed for the knee. Anything else at home? Vitamins, teas, anything from the botánica?

PTManzanilla tea, but that's for the soul, not the body. Otherwise just the naproxen. That's all.

DRReconciled and official. Let's look at your numbers, because you earned some good ones. Blood pressure today: 135 over 82. The top number is a touch above perfect — not medicine territory, but we watch it. Heart rate 60 and steady, breathing 12, and your weight is 73.8 kilos.

PTDown! I was 78 once upon a time in that chart, I remember it.

DRDown indeed — your BMI is 27.7 now. The market walks and the war with the zucchini are working. Now the blood tests from this morning. Your sugar average — the A1c — is 6.11 percent. Still prediabetes, same neighborhood as last year, holding steady. Today's sugar was 79, which is lovely. Kidneys perfect — creatinine 0.68. Sodium 138, potassium 3.9.

PTAnd the cholesterol? That's my inheritance, my mother had it too.

DRYour inheritance is behaving. Total cholesterol 168, the bad LDL is 87, the good HDL is 59, triglycerides 110. For someone with hyperlipidemia on the books, these are genuinely good numbers.

PTThe oatmeal gets the credit. And less rice than before — my daughter measures it now like a pharmacist.

DRKeep the pharmacist on staff. Blood count: hemoglobin 16.9, hematocrit 47.6 — no sign of the old anemia today, your iron story looks closed. Platelets 351, white count 7.4, all in order.

PTSo the blood is rich again. Good. I told you the lentils would do it.

DRYou did tell me. Now open wide for me — I want to check your mouth. Mm. Your gums are puffy along the bottom, and they bleed a little when I touch them. Do they bleed when you brush?

PTA little pink when I spit, yes. I thought that was normal at my age.

DRIt's common, not normal — it's gingivitis, the early, fixable kind of gum disease. I'm sending you to the dentist for a proper cleaning.

PTAy, the dentist. Fine. But I want it known I go under protest.

DRDuly recorded. Brush twice a day, soft brush, and don't stop when it bleeds — that part gets better in a couple of weeks. Now, one more thing: your flu shot. I know it's only August —

PTAlready? The children aren't even back in school!

DRYou're here, the vaccine is here, and the calendar has a way of eating good intentions. Same one as every year, the trivalent.

PTFine, fine. Left arm. The right one stirs the pots.

DRPerfect. So, the summary, Mrs. Casas: sugar — steady, keep the walks and the measured rice, we recheck next year. Cholesterol — excellent, keep the oatmeal. Knee — naproxen as needed with food is exactly right. Weight — moving the right way, well done. Mood — mild five a.m. worries, we keep an ear on it. Gums — dentist, under protest. Flu shot today. Questions for me?

PTOnly one. The grandchildren bring home every germ ever invented. The flu shot covers me for their whole plague season?

DRThat's exactly why we're doing it today — grandmother of three is a frontline occupation. Wash the hands, get the sleep, and you're as covered as I can make you.

PTThen jab me and I'll go liberate my tomatoes from the waiting room.

NURSEI heard there are tomatoes involved. Left arm? Little pinch... there, done. Pressure for a minute, and thank you for the bag, Mrs. Casas — you're everyone's favorite Tuesday.

PTFlattery accepted. Same time next year, Doctor — God willing and the zucchini permitting.