Beer Belly

There actually is a prosthesis--like a CamelBack only not quite--to carry beer outside your gut instead of in, as seen here. A patient I saw this last week had been working for twenty-five years in order to avoid this problem by just drinking until he had a beautiful beer gut to call his own. Or so we thought.

He came in with just some fractured ribs. Three days later he had gone into kidney failure and had a potassium of 6.9 at the highest, normal being 4.8. He had EKG changes and depressed mental status, shortness of breath. He got dialysis and an endotracheal tube. He felt better.

In the midst of all that running around and worrying that this large man on a small bed was going to crash and die, I never thought twice about his body habitus; facial and central obesity is nothing new in Wisconsin.

It was only when his parents arrived a few days later and said, 'we're still trying to figure out why he gained 90 pounds last year'. Last year? He grew that much in a year?

Ah, the medicine differential. So long, so complicated, so fundamentally useless. I did a longer interview, and eventually came up with a variant of Cushing's disease, or pseudocushing's disease; atypical rheumatoid arthritis, atypical sarcoidosis, perhaps histoplasmosis, even intestinal angioedema from his ACEI--all this in the setting of a CT scan of his abdomen with no free fluid and a normal cardiac echo, as the most common reasons for weight gain are fluid related (ascites, heart failure). I even talked the team into a serum cortisol and some enzymes. Nothing found.

He had a history of boxing, was actually 49-4; perhaps a late lesion of the medial hypothalamus? He had been suffering from night sweats for thirty years--autoimmune disease? Cancer?

On a surgery service, he was treated for his ribs and went home.

Reality 1, Ockham's Razor, 0.