Mr. Claus is here today for a routine physical. With his permission we also discussed his unique medical issues as a parallel sort of visit. Mr. Claus continues to work long hours and reports stable complaints of joint aches, interrupted sleep, slow urine stream, and a chronic cough. He had Covid a couple weeks ago, but it felt like a mild case, and his cough predates this illness. He received the XBB booster a couple months ago, and was treated with Paxlovid. No long haul symptoms reported. Otherwise Mr. Claus reports feeling some stress and anxiety. He will be delivering toys and goodies to billions of people across the world while flying in a sleigh pulled by reindeer, per usual.
No chest pain, fever, hemoptysis, blood in stool, or abdominal pain. He does have that chronic cough for years. Has smoked a pipe for many years. Despite stress levels being high, he reports that his mood is jolly.
Hypertension: blood pressure not at goal. Discussed reducing sodium in diet, less total calories to achieve weight loss, staying active with exercise as tolerated, and walking instead of taking the sleigh when possible. Stress reduction techniques. Added hydrochlorothiazide and potassium supplement, discussed possible side effects. May help mild edema, may worsen urinary complaints. Follow up in 1 month. Telemedicine visit is probably ok if monitoring home blood pressure at 90° north latitude.
Impressive beard: patient questions the health risks/benefits of maintaining legendary beard. Reassurance given that beards may block some UV damage and slightly buffer against cold exposure, but must be groomed and kept clean. Studies have shown that traits people tend to associate with beards include aggression, dominance, and maturity. A clean-shaven look is more associated with sociability, good health, and cleanliness. Beards may affect self-perception, so depending on which of the above outward signals need adjustment, groom as needed.
Prediabetes/impaired fasting glucose: continue efforts to lose weight. Take a walk after dinner and other meals if possible. Reduce simple carbohydrates like bread, pasta, rice, potatoes. Reduce or eliminate sugary foods, juices, cookies. Eat the carrots left out by children instead of the cookies. This will please children’s parents, as they tend to argue about who has to eat the dried out carrots before bed.
Chronic cough: reviewed low dose CT from last year and pulmonology consultation, pulmonary function testing consistent with mild COPD. Total smoking cessation advised, even pipe smoking is risky. Encouraged to set a quit date, and offered Chantix prescription to help. Annual low dose CT ordered for lung cancer screening, consider Symbicort inhaler for symptoms, at this time patient declines. Pneumonia, RSV, flu, and Covid shots are all up to date. Mr. Claus doesn’t play around, and understands the nuanced truth that while vaccines are not risk free, they are assuredly better than contracting the targeted diseases unvaccinated. Limit exposure to products of combustion such as pipe smoke, fireplaces, and even burning excessive candles indoors.
Post Covid condition manifesting with cough: recent Covid illness likely contributing to chronic cough. Added benzonatate for cough suppression. Advised to wear a good mask while visiting billions of households. Chronic soot exposure from chimneys is likely contributing to cough as well. N95 mask should help filter 0.3 micron-sized sooty particulates. Reminder that OSHA does not recommend entering chimneys in general, as there is significant risk of injury and getting stuck. Make sure that disability insurance is occupation specific and does not have disclaimers for chimney climbing. Many cases of chimney burglaries are in the news, and often end badly. Assume American homes are full of guns and angry partisans.
Obstructive sleep apnea: continue CPAP, avoid alcohol at night, continue weight loss efforts.
Edema: check labs as ordered today, check echocardiogram to assess for valvular regurgitation, ejection fraction, and pulmonary hypertension. Consider stress testing, ultrasound for venous insufficiency. Will return to office to discuss first round of testing. Continue compression stockings.
Rosacea: patient declines treatment for rosy cheeks, states this is part of his mystique. In general rosacea will be exacerbated by exposure to cold and wind, alcohol, and stress. Consider metronidazole gel.
Slow urine stream: check PSA against baseline, and referred to urology for full evaluation. Benign enlargement suspected on DRE, but rule out more serious prostate problems. Urination tips briefly reviewed.
Osteoarthritis: seems like typical wear and tear complaints, but since diffuse arthralgias, will add Lyme disease screen, autoimmune and rheumatoid markers. Acetaminophen safer than NSAIDs like ibuprofen.
High cholesterol: stable, continue statin, monitor liver enzymes. Healthy diet, Mediterranean style if possible at North Pole. A diet similar to the Inuit people that is high in saturated fat from seal and other animal fat/meat has been mythologized as healthier. Recent analysis finds otherwise.
Mild constipation: apples noted in picture above should be quite helpful, and a recent clinical trial showed that eating two kiwi fruits a day is as effective as a daily fiber supplement, even for irritable bowel syndrome with constipation. Colonoscopy is up to date and no significant changes in bowel habits reported.
Umbilical hernia: reviewed signs and symptoms of incarceration, go to ER if these occur. Otherwise he prefers to observe, and defers elective repair. Avoid straining, heavy lifting, and consider supporting the area with a firm hand while coughing. Continue working on weight loss. Return to office if GLP-1 agonist for weight loss is desired, can discuss Wegovy and Zepbound. Demand is high, supplies are very limited, and potential for side effects and adverse effects needs to be reviewed.
Encounter for general medical exam: Healthy diet is recommended, maximizing plant, fruit, vegetable intake, while minimizing saturated fats like meat, butter, fried foods. Limit/avoid ultra-processed foods, simple carbohydrates, candy canes. Regular exercise recommended, chimney climbing if necessary, stay active during the daytime, avoid prolonged sedentary times. If drinking alcohol please do so in moderation, 1 drink per day average for women and 1-2 average for men - but the less alcohol the better. Yearly PSA testing until 70 years old is suggested although there is a risk of false positives and many authorities recommend against PSA screening in general. Referred to urology as above. Daily vitamin D 600-800 international unit(s) especially in the winter may help. Check routine labs. STD testing optional. Please check MyChart or call for results of any testing, normally within a few days results are available. Remain vigilant for any skin lesions/dark moles, review ABCDs of early melanoma detection. Reduce stress with behaviors like exercise, meditation, breathing techniques, and try to get 7 hours of sleep per night.
Immunization counseling: reviewed and recommended according to CDC/ACIP adult schedule. Yearly influenza vaccination should reduce the risk of flu by at least 50%. New RSV vaccines seem quite safe and effective so far, with millions of doses given and no red flag safety signals reported at this time, can expect a reduced risk of infection by ~80% and severe disease by >90%. Shingles vaccine already completed, over 90% reduction in shingles risk is durable. Received Covid booster, and with recent mild infection has good hybrid immunity against severe disease. Treat with Paxlovid if recurs. Tetanus booster given today including pertussis component for whooping cough given exposure to many newborns, and high risk chimney activities and risk of dog bites. Please call with any concerns, and yearly physical advised.
Stress: deep breathing (the book Breath is good), meditation (the app Meditation Oasis is good and cheap), exercise as tolerated with arthritis (caution with pickleball), and consider work/life rebalance in the new year. Gave him many thanks, and expressed my admiration for his work.
Happy Holidays! Schedule your primary care check up for 2024 if you haven’t had one recently. Most likely it will take months to get in. Sorry, it’s not the players’ fault, it’s the game. And this routine “physical” represents why we are always running late in the office, and while artificial intelligence will be helping us (but not be replacing us) anytime soon I hope!
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And if you’d like to read more vital and overlooked ideas your family doc might share (if only we had more time), add your email address to a Substack I write called Examined 🙂
