Wednesday, September 26, 2007

Crazy People Get Sick, Too

During medical school, several of us wrote down funny quotes from different speakers throughout the year, and then some of the best ones were printed on our class t-shirt. One of the better ones was, "Managing physicians is like trying to herd cats." Another favorite, "Crazy people get sick, too. Don't get distracted by all of the craziness."

The other day I almost missed a bread and butter diagnosis. This guy came in complaining of a headache for three months, chest pain for two days, and abdominal pain for twelve hours. He was really distractable, and the more I tried to get him to focus on one thing or another, the more symptoms he kept developing... like insomnia, and left ankle pain. Perhaps I was already annoyed by my ongoing cold and the opportunity to hone my mouth-breathing skills, but I just was losing all of my patience with this guy. It didn't help either when later he started having pseudoseizures... he would start twitching at random, but still was able to answer questions and follw commands, like from the nurse to "Stop twitching and hold still so I can start this IV."

Annoying, just annoying.

Somewhere along the history of present illness for his headache, he told me that the only thing that made his headache of three months better was, "Stabbing myself in the temple daily with a butter knife."

Review of his daily meds revealed two narcotics, and an asthma inhaler.

Review of his computer chart revealed a previous mention of schizoaffective disorder... for which he was not currently being treated. It was becoming clear to me that this guy hadn't just "slipped through the cracks" with regard to follow-up care, it was more like he had fallen down a gorge and the vultures were circling.

So I called the psychiatry resident on call, and told them that I was working on clearing him medically for his chest pain, headache, and abdominal pain. However, what he really needed was assessment and follow-up with a therapist and a psychiatrist.

Easy enough, right?

Things got a little busy in the trauma room, and the next thing I know my personal intercom is going off while I'm putting in a central line. It is his nurse. She tells me that his blood sugar is 690. (Normal is 70-110 fasting, or less than 200 after eating.)


Not only is this guy an undiagnosed diabetic, but he is in DKA and as all of his bloodwork starts coming back, it is becoming apparent that he is actually quite sick. Fortunately, he had already been started with IV fluid replacement, but I could have been a lot faster with the insulin therapy had I not so been distracted by all of his psych stuff.

He actually ended up getting admitted to the ICU for monitoring, but should be discharged by now after having received diabetic teaching and started on new meds, and will be seen by the psychiatry service before discharge. Before he went upstairs, he thanked me for taking his complaints seriously. I felt like such a jerk. I guess that's why we do lab workups on our psych patients.


ru said...

Psych stuff is distracting; I'm glad that you didn't blow him off entirely.

Chris said...

I would have been worse....I would have just told him to quit stabbing himself in the head with a butter knife and the headaches would go away:)

Shazam! said...

Kate, this is great. I thought you were going to say that he had a butter knife in his brain. I guess it's a good thing the knife was dull!