•
A few years back—before diabetes and really having to watch my diet—Bill and I decided to work on our mutual weight problem by walking. So, at night we would walk to the Baskin-Robbins ice cream shop to have an ice cream cone night cap. And in the mornings we would walk to the Yum Yum Donut shop for our usual hot coffee and warm maple bars. On one particular morning, we had made it to Yum Yum’s in record time, and I reached in my sweater pocket for the twenty dollar bill I had brought along. Bill didn’t have his wallet with him, and I had left my purse at home because heavy purses aren’t much good on brisk walks.
We ordered our usual, and when the girl brought it, I plunked my twenty down on the counter. She took my money and disappeared to the back room to get cream and more napkins. When she returned, she asked for two dollars and fifty cents. She didn’t speak very distinct English, but she made it clear she expected money. And I told her she had just picked up my twenty dollar bill when she had gone out back for more cream.
It didn’t make any difference. All she could keep saying was that we owed her two dollars and fifty cents, and she didn’t seem to “understand” about the strange disappearance of my twenty dollar bill! By this time, people were coming in the door and standing in line, all waiting to order their coffee and donuts. Bill was getting annoyed with all this fumbling around and tried to come to my aid. After all, he had seen the girl pick up the twenty dollar bill I’d laid down. So had another lady who had been sitting near by.
I thought, Who do you call at a time like this? Bill suggested cleaning out the cash register and PROVING she had taken our money. I also thought of calling the police but decided against it. They might not believe us, and we couldn’t prove we put the money on the counter.
Very much embarrassed, we took the coffee and maple bars to a little table and sat down. I began planning on how we could leave if she still insisted we owed her money. We had no more money with us. And what if she called the police and said we couldn’t pay her for what we ordered? Bill already had taken a bite out of his maple bar, and we couldn’t return it . . .
I tried to appear unobtrusive, glancing at a newspaper lying on the seat next to me and reading the signs on the window, but Bill kept muttering loudly, saying things like, “This is the most expensive donut and coffee I’ve ever had—TWENTY DOLLARS FOR TWO MAPLE BARS AND COFFEE!”
We finished our maple bars and coffee and left without the girl trying to stop us. Bill kept yakking about it as we walked back home, wanting ME to call the main office of the Yum Yum Donut Shops and complain that they had taken our money. All the way back he fumed about paying twenty dollars for our small order. Suddenly I remembered that several years ago, in front of our church, I had FOUND a twenty dollar bill.
“Hey, Bill, remember when I found that twenty dollar bill a few years ago by our church?”
Bill didn’t remember. But I told him, “Why not look at it this way? That was the same twenty dollar bill we lost today, so really we got the maple bars and coffee for FREE!”
Bill looked at me as if I were someone from outer space and continued being depressed about losing that much money. For a couple of weeks, his irritation over the whole episode left a heavy cloud over everything.
With his melancholy temperament, he harbored ill feelings. He didn’t want to go back to the Yum Yum Donut Shop and preferred nourishing the idea that he had been done wrong. But I had decided I had more enjoyable things to do than worry about a lost twenty dollar bill, especially since, the way I looked at it, we really got the maple bars for free!
*3\316\2*
DIABETES: TWENTY DOLLARS FOR TWO MAPLE BARS?A few years back—before diabetes and really having to watch my diet—Bill and I decided to work on our mutual weight problem by walking. So, at night we would walk to the Baskin-Robbins ice cream shop to have an ice cream cone night cap. And in the mornings we would walk to the Yum Yum Donut shop for our usual hot coffee and warm maple bars. On one particular morning, we had made it to Yum Yum’s in record time, and I reached in my sweater pocket for the twenty dollar bill I had brought along. Bill didn’t have his wallet with him, and I had left my purse at home because heavy purses aren’t much good on brisk walks.We ordered our usual, and when the girl brought it, I plunked my twenty down on the counter. She took my money and disappeared to the back room to get cream and more napkins. When she returned, she asked for two dollars and fifty cents. She didn’t speak very distinct English, but she made it clear she expected money. And I told her she had just picked up my twenty dollar bill when she had gone out back for more cream.It didn’t make any difference. All she could keep saying was that we owed her two dollars and fifty cents, and she didn’t seem to “understand” about the strange disappearance of my twenty dollar bill! By this time, people were coming in the door and standing in line, all waiting to order their coffee and donuts. Bill was getting annoyed with all this fumbling around and tried to come to my aid. After all, he had seen the girl pick up the twenty dollar bill I’d laid down. So had another lady who had been sitting near by.I thought, Who do you call at a time like this? Bill suggested cleaning out the cash register and PROVING she had taken our money. I also thought of calling the police but decided against it. They might not believe us, and we couldn’t prove we put the money on the counter.Very much embarrassed, we took the coffee and maple bars to a little table and sat down. I began planning on how we could leave if she still insisted we owed her money. We had no more money with us. And what if she called the police and said we couldn’t pay her for what we ordered? Bill already had taken a bite out of his maple bar, and we couldn’t return it . . .I tried to appear unobtrusive, glancing at a newspaper lying on the seat next to me and reading the signs on the window, but Bill kept muttering loudly, saying things like, “This is the most expensive donut and coffee I’ve ever had—TWENTY DOLLARS FOR TWO MAPLE BARS AND COFFEE!”We finished our maple bars and coffee and left without the girl trying to stop us. Bill kept yakking about it as we walked back home, wanting ME to call the main office of the Yum Yum Donut Shops and complain that they had taken our money. All the way back he fumed about paying twenty dollars for our small order. Suddenly I remembered that several years ago, in front of our church, I had FOUND a twenty dollar bill.”Hey, Bill, remember when I found that twenty dollar bill a few years ago by our church?”Bill didn’t remember. But I told him, “Why not look at it this way? That was the same twenty dollar bill we lost today, so really we got the maple bars and coffee for FREE!”Bill looked at me as if I were someone from outer space and continued being depressed about losing that much money. For a couple of weeks, his irritation over the whole episode left a heavy cloud over everything.With his melancholy temperament, he harbored ill feelings. He didn’t want to go back to the Yum Yum Donut Shop and preferred nourishing the idea that he had been done wrong. But I had decided I had more enjoyable things to do than worry about a lost twenty dollar bill, especially since, the way I looked at it, we really got the maple bars for free!*3\316\2*
•
When a history and physical examination suggest bacterial meningitis, the practitioner should proceed swiftly to lumbar puncture to establish a diagnosis. However, the clinician is faced with the question of whether the procedure will put the patient at risk for herniation and subsequent neurologic deterioration. To assess this risk, physicians often order head computed tomography (CT) scans prior to performing the procedure. In certain populations, provided there is no delay in delivery of empiric antibiotics, this approach may be appropriate.
It is generally accepted that patients with coma, papilledema, or other focal neurologic deficits should undergo neuroimaging prior to lumbar puncture for suspected acute bacterial meningitis. Hasbrun et al have determined that in such patients, head CT scanning should be used in making the decision to perform lumbar puncture.
A recent prospective study has confirmed, however, that clinical features can be used to determine which patients are unlikely to have an abnormal CT scan and can thus undergo lumbar puncture without delay. In this study of 235 patients who underwent a head CT scan prior to lumbar puncture, abnormalities were more often associated with certain historical features and neurologic findings. Patients older than 60 years with known immune deficiency (due to human immunodeficiency virus, immunosuppression, or transplantation), central nervous system disease, or a history of seizure 1 week prior to presentation were more likely to have abnormal head CT scans. Patients with focal neurologic findings were also more likely to have abnormal scans. In the patients with none of these features, only 3% of the CT scans were abnormal, and there was no evidence of mass lesion or herniation risk that precluded subsequent lumbar puncture. Kastenbauer et al retrospectively studied the records of 75 adults with pneumococcal meningitis and similarly determined that patients with focal neurologic deficits, seizures, and reduced level of consciousness (Glasgow coma score <12) were more likely to have head CT abnormalities.
*3/348/5*
•
It is very important, therefore, that we discern stage two symptoms for what they are, so that stress breakdown can be prevented from getting worse. The most common misdiagnosis in stage two stress breakdown would be to mistake the symptoms for those of endogenous depression.
Endogenous depression is primarily a mood disorder in which the person feels weak and tired, experiences broken sleep or early-morning waking, feels worse at a particular time of day, especially in the mornings, and feels generally sad, sometimes enough to suicide. Stage two symptoms can resemble depression, but there are differences:
1. The sleep disorder in stage two stress breakdown tends to be one of difficulty in getting off to sleep, while in endogenous depression, the patient has difficulty in staying asleep.
2. The person with stress breakdown often feels better after a night’s sleep, while the person with endogenous depression may feel worse.
3. There may be a tendency to burst into tears in depression, but the emotional lability of stress breakdown is one of inability to control both high and low swings in mood, momentarily.
4. In endogenous depression, the atmosphere portrayed by the patient is one of loss – loss of energy, loss of enjoyment of life, loss of the will to live. In stress breakdown, the atmosphere is one of load. Suicide threats expressed in stress breakdown are impulsive gestures of despair and not based on the quiet, sad conviction of the patient with endogenous depression that the world would be better off without him.
*22/129/5*