Doctors Lounge - Endocrinology Answers
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Forum Name: Endocrinology Topics
|js2777 - Wed Mar 01, 2006 12:13 am||
I am a 28 year-old male, 6' 280lbs, who has stumped my doctor over the past two years. It began with mild depression for which I was given Lexapro. Five hours after taking that I experienced my first ever panic attack. Since then the anxiety or nervousness has continued and the depression comes and goes. I also am experiencing chronic headaches, body aches (particularly in the ribs, upper back, and legs), palpatations, occasional tingling in both arms that travels to my hands, pressure at the base of my throat, and lightheadedness and difficulty concentrating. All of these symptoms vary in intensity from day to day.
During this time I visited the ER twice with tachycardia and chest tenderness. All blood normal except slight kidney elevation, normal EKG and chest X-ray. Last month I had an endoscopy that showed a hiatal hernia and barrtett's esophegus. I have GERD and IBS which have both gotten worse over the last two years. I have had bowel obstruction surgery twice, in 1977 and 1999. Through X-rays in 1999 prior to surgery I was diagnosed with fibrous dysplasia in a part of my pelvis. I was diagnosed with SVT in 1993 and had cath. ablasion with no problems until two years ago. I am currently on Prevacid 30mg twice daily.
I have the general feeling like something is wrong with me. I am constantly tired, yawning, and sighing. I am frustrated and want to feel better. Any advice or insight would be greatly appreciated.
|Dr. Shank - Sat Mar 11, 2006 8:23 pm||
Many of your symptoms can easily be explained by hyperventillation. While commonly referred to as a "panic attack," panic is merely one of the many possible symptoms. In essence, you breath too deeply and too fast, and you blow off too much carbon dioxide from your blood. That causes a lot of very unpleasant symptoms, including severe anxiety or panic, sense of impending doom, palpitations, chest pressure or pain (usually across the entire chest), numbness or tingling in the scalp, face (especially around the mouth), arms, fingers, and (occasionally) the legs and feet, lightheadedness, and dizziness. To make matters worse, you feel as if you are sufficating, and you have probably been told to do things that only aggravate it (like: "Take deep breaths," or "Blow into a paper bag.") The list of things that can cause hyperventillation is extremely long, but depression and anxiety (both of which you have) are the most common, by far. Most people have at least one episode during their lives, but it is extremely disabling to those who have it frequently or who live in fear of experiencing it again, even if they fully understand that it is harmless. The best treatment is prevention, but when that is not possible, trigger a reflex that shuts down your breathing! When I was a graduate student in physiology, there were two reflexes which my professors confidently declared as absolutely useless and which I figured out uses for within twenty minutes that I still use in my clinical practice thirty years later. One of them is the reflex that protects your lungs from being overfilled. Since a person who has hyperventillated feels an overwhelming urge to breath, I encourage him to breath in as much as he can--until it hurts. Then I instruct him to hold his breath. Because of this reflex, he can do so very easily (If he were really sufficating, as he feels he is, he would still not be able to hold his breath.). As he holds his breath, carbon dioxide levels start to build back up, and he begins to feel better. When he can no longer hold his breath, I encourage him to let it out as slowly as he can and repeat the process. Within two or three breaths, most people are feeling almost normal-which is a lot faster than a pill can work, and a whole lot faster than going to the emergency room!
The sensation of pressure in the back of your throat might also be related. "Globus" (the sensation as if you had a ball in your throat) is more formally known as "globus hystericus," which just assumes that anyone who has this sensation is just imagining it. Common physical causes that I have seen include enlarge thyroid gland (goiter), large thyroid nodules or cysts, and brancheal cleft cysts. The later are usually mistaken for thyroid nodules. Radiologists (who have no business working up thyroids, in the first place) uniformly conclude that they are suspicious for thyroid cancers. Brancheal cleft cysts are very interesting, because they are connections to the trachea found in about 15% of adults, can rapidly fill to very large sizes with secretions that can just as quickly discharge into the trachea as an extremely thick and tenacious fluid.
Anyone with a supraventricular tachycardia or recurrent hyperventillation syndrome should have his levels of TSH, free T4, and free T3 checked. Of course, the thyroid should also be checked in anyone who is always tired. The normal ranges for free T4 and free T3 vary with the lab (for free T4, it should usually be in the mid-to-upper portion of the lab's reference range; for free T3, it should usually be in the mid-to-lower portion of the lab's reference range). According the the American Association of Clinical Endocrinologists and the American Thyroid Association, the TSH should be between 0.3 and 3.0, regardless of what the laboratory's reference range is (Actually, I find that most individuals with TSH levels that are persistently 1.5 to 3.0 are also clinically hypothyroid and benefit from higher levels of thyroid hormones.).
The fatigue and yawning could be do to abnormal thyroid or a varieity of other endocrine problems, but I would be very concerned about a sleep disorder, such as narcolepsy or sleep apnea.
Unless there is an obvious cause that responds appropriately to treatment, chronic headaches deserve a work up. Period. Common causes include sinus and middle ear congestion or infections, migraines, obstructive sleep apnea and "turtle" headaches (from pulling your head under the covers when you sleep, like a turtle), and chronic use of pain medications. Another cause is postconcussive headaches (often of the migraine type and often difficult to treat). More serious causes include brain or pituitary tumors.
Irritable bowel syndrome is a diagnosis that I would make with a great deal of caution in someone who had twice had bowel obstruction. Around here, IBS means nothign more than, "We've already been paid for running tubes from both ends toward the middle, and we don't want to be bothered with figuring it out, when we could be making real money, instead of wasting our time on office visits and ordering tests that we can't bill for."
If these basics have been addressed and you still do not have a satisfactory answer, I would point out that my practice is also located in Ohio.
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