Symptoms you should never ignore

A few years ago, while in my office awaiting a morning appointment, I heard the screech of brakes followed by a loud crash. I rushed outside to find the would-be patient, a 60-year-old accountant, slumped over the steering wheel of his car, which had all but demolished a parked van. His speech was slurred and he appeared dazed as he was being loaded into an ambulance.

Rewind the tape to three years earlier, when the patient began having spells of anxiety, a rapid heartbeat, and sweating every few months. In between episodes he was perfectly fine. Eventually another symptom appeared—bouts of abusive behavior toward his wife, who learned that she could calm him down by feeding him sweets.

He sought help from an internist, a cardiologist, a neurologist, and a psychologist, none of whom could find a cause for his problems. The psychologist sent him to me, thinking that he might have low blood sugar. He told the man to fast before the visit so that the blood tests would be accurate. Ordinarily that would have been sensible advice, but in this instance it led to disaster. Tests in the ambulance found that the patient's collapse at the wheel was caused by a blood sugar level of 14 milligrams per deciliter. The normal range is 70 to 110.

Symptoms that come and go are challenging to patient and physician alike. But they are not to be dismissed, because they can signal serious, even life-threatening conditions. Here's a rogue's gallery of the most significant ones.

• Abnormal heart rhythms, such as atrial fibrillation. Many a trip to an emergency room has been for naught as the pal­pitations suddenly subside in the waiting room. Ambulatory electrocardiographic monitoring is often needed to catch the culprit in the act, because an accurate diagnosis is essential for proper treatment.
  
• Transient ischemic attacks (TIAs) or mini-strokes. Caused by vascular disease in the brain, which causes speech and balance problems or facial or limb weakness or numbness. Between attacks, the victim feels fine. Blood thinners can lessen the likelihood of a full-fledged stroke. 
  
• Atypical seizure disorders, or isolated, brief episodes of abnormal behavior or visual or auditory hallucinations. I recall a patient with a brain tumor whose initial symptom was hearing fragments of classical music.
• Assorted rare hormone-producing tumors. One type of adrenal tumor, for instance, can produce surges of adrenalin, resulting in light-headedness, palpitations, and headache.

As a patient, your most important tool is your intimate knowledge of your symptoms. Your goal should be to communicate them to your doctor in as much detail as you can manage, and:

• Leave nothing out, even if you don't think it's within the professional purview of the specialist you're seeing. I once had a patient whose serious pituitary disorder, Cushing's disease, went undiagnosed for five years because she went to an internist for her diabetes, a cardiologist for her hypertension, an orthopedist for her backache, and a dermatologist for her easily bruised skin, and never mentioned all four symptoms, highly characteristic of Cushing's, to any of them.
• Describe your symptoms in context. If they change after, say, eating or physical activity, be sure to mention it. A patient scheduled for surgery for a slipped disk in his neck mentioned during his preoperative consultation that movement didn't make his pain worse but climbing stairs did, a fact he had never shared with his orthopedists. It turned out that his neck was not the problem; the symptoms were caused by coronary artery disease.
• Be persistent. Don't give up if the first doctors you see can't figure out what ails you. The accountant's insistence on seeking new opinions—ill-timed car crash notwithstanding—ultimately led to a proper diagnosis and cure.

Tests in a hospital revealed that he had a small, rare benign tumor on his pancreas that was pumping out huge quantities of insulin, which in turn was causing his blood sugar to plummet. Eight years after surgery to remove it, he remains well and symptom free.