Patients: August 18, 2005

Herman

Sam's patient. A more clear picture emerges as Sam and I learn more about Herman's medical history. Sometimes settling on the correct diagnosis takes a long time. Sometimes getting the correct diagnosis doesn't occur until it is too late to provide reversible treatment. And sometimes, getting the correct diagnosis results in hopelessness.

Five months ago, Herman was initially diagnosed with rheumatoid arthritis, an autoimmune disease involving both large and small joints. The pain is managed with non-steroidal anti-inflammatory drugs (NSAIDs). More severe cases may be treated with corticosteroids, which will suppress the patient's immune system with greater effect. This is what Herman was taking. It was a couple months later when the Rheumatology Department referred Herman to Hem/Onc for re-evaluation. More poking, more probing, and more tests led to a preliminary diagnosis of acute myelogenous leukemia (AML). Treatment includes chemotherapy, transfusions, antibiotics, and bone marrow transplant. I mentioned previously Herman's platelet level, which was so low that he couldn't brush his teeth or shave his beard. Surgery doesn't dare to touch him. To make matters worse, Herman's chest X-ray indicates that he has developed a fungal infection in his lungs due to his immunosuppressed state. It was decided that the best course of action was to wean Herman off the corticosteroid to help fight off the infection.

However, according to Herman's wife, as Herman came off the medication, his mental status became more unstable. His delirium has become increasingly more severe and his memory is starting to fail. To his family, Herman has become a shadow of his former self. Herman's wife refuses to let her son visit with Herman in this condition. She'll tell anybody who will listen: "Herman did so much better on the steroids. This isn't living. You don't know Herman - this isn't him. I want my Herman back."

Meanwhile, the raging fungal infection in his lungs hasn't resolved. Prognosis for AML depends on subtype, but in general, 70-80% of adults achieve complete remission. I'm not exactly sure why Herman's prognosis remains poor, but I surmise that the oncologists' reluctance to start chemotherapy is an indication of his compromised health. Herman's wife wants him back on steroids, thinking that the drugs will somehow normalize his mental status. Of course, there's no guarantee that this will happen, but the steroids will make fighting the infection much more difficult. She must know this, yet she continues to press. Has she given up? Does she just want a few more days with the Herman she knew before he passes on?

Why are the oncologists so reluctant to submit to the wife's orders? Physicians often have a hard time letting patients go, too. Physicians often equate losing a patient with failure. It's possible that it is much too early to throw in the towel, but it's certainly been a long five months for Herman's family, and they must be horrified at the possibility that they've already lost the Herman they knew.


Clive

Clive is a 41-year old male who just had an aortic aneurysm repaired. He is being held for observation because the surgical incision has become infected. Clive was diagnosed with schizophrenia in his late teens. A snapshot of schizophrenia:

• affects 1% of the population, usually diagnosed in the 20s for men and women
• positive symptoms: hallucinations, delusions, bizarre behavior (aggression/agitation, odd clothing, etc)
• negative symptoms: flat affect, alogia ("lack of words"), few friends or interests

Psychiatry Consult has been requested because Clive seems to be managing the health staff, rather than the staff managing Clive's health. I've noticed that a common theme with psychiatry consults is that the psychiatrist is called in to deal with patients that are annoying the heck out of the nurses. Whatever. I'm excited to meet my first schizophrenic patient.

Clive is lying in bed when we walk into his room. He's alert, oriented, and very cooperative despite having a flat affect (his stoic expression never wavers). He is keenly aware of his mental status, and is obviously experienced navigating his way through the hospital system. He recites his primary care physician's phone number from memory. At the end of the interview, Dr. Berg turns to the medical students.

Dr Berg: Okay, who wants to pick him up?
Sam hesitates. Not wanting to look reluctant, I volunteer to follow-up Clive. Later, I apologize to Sam, thinking I may have stolen the patient right from under his nose.
Sam: Nah, man - I wasn't sure what he meant. I thought he wanted one of us to lift him.
(Oh, Sam - such a literalist.)

I return to Clive's room in the afternoon to perform a more thorough mental status exam. It ends quickly.
Mikey: Hi, Clive - remember me? I'm part of the team taking care of you. Would you mind answering a few questions?
Clive: Well...do I have to?
Mikey: I'm not forcing you to do anything.
Clive: Well...okay.
Mikey: Great, thanks. So how are you feeling today?
Clive: Not well. Look, I've just taken a Klonopin and I'm not up for this. NOW GET OUT!
(Okay, I made up that last part).