The Rising of the Phoenix

A few days ago I wrote a brief blog entry entitled "Out of My Mind" which was about a 29 year old female in the midst of a psychotic break. It was hard to give the reader an accurate idea of how psychotic this patient was through words alone. You really had to be there to understand how lost this patient had become. Nothing she said made sense. She nervously scanned the room with her eyes and her limbs twitched with restlessness. As I asked her questions her responses seemed to have zero connection to reality.

I asked "how old are you" and she replied "Surgo is 40, so I am 1, 2, 3, 4 months old" I asked "Who is Surgo?" and she said "Surgo is the top half of my body". These kinds of responses continued for nearly 30 minutes at her intake interview. She was hypersexual and exposing herself and trying to initiate sexual acts with the other residents and some of the staff. 

This psychotic behavior continued for nearly 3 days without any noticeable improvements. Initially we started her on an antipsychotic and after 3 days without improvement, yesterday I doubled her dose. 

This morning when I interviewed the patient I immediately noticed that a complete transformation that had occurred. Today she was fluid and congruent. Her responses made sense. The nervous twitching and restlessness was no longer present. She asked "when can I go home? I feel much better." It was like I was talking with a different person. I asked her about the previous days and some of the statements she had made. She did not recall most of it and simply explained that she had been very confused and scared and knew something was wrong. She was grateful and when I asked her "how do you think you got better" She said, "it is all because of you doctor" I smiled and said "I think it has more to do with the medication, but thank you."

I was walking the patient back to her room and she grabbed my arm and said "everyone will think we are going out" I said "do you think this is appropriate behavior?" She quickly replied "oh come on, I have been telling everyone that we are dating and I do not want them to think I am a liar." She made the statement in a joking manner and knew she was being silly which was a good sign that her insight into her illness was returning. We were at the door to her room and I said you are healing, please continue to take your medicine and we will hopefully be able to discharge you soon. 

These are the cases that make the psychiatrists really appreciate their job. I think all the fields of medicine have patients that make a tremendous comeback and these cases help ease the more difficult cases that do not seem to recover. 

What a great day!

Are you Impulsive

We had a great lecture this week from a world expert psychiatrist on impulsive behavior and it was very enlightening and frightening at  the same time. What is impulsive behavior? To keep things simple I will explain the concepts without all of the medical jargon. Basically and impulse is a thought about doing something. Impulsive behavior is often defined when pathologic as the inability to define or evaluate a behavior / action in the context of its environment. Imagine sitting in a lecture and you suddenly feel like taking your pants off. Hopefully with your functioning brain you would realize that in the given environment it would be inappropriate to take your pants off and thus you would refrain from taking your pants off. In a different environment it may be perfectly acceptable to take your pants off; like in a dressing room or a locker room or in your bedroom. All of this modulation of behavior and ultimately the action or refrain from action is mostly carried out on a subconscious level meaning you are completely unaware of this occurring in your brain and it occurs in milliseconds.

Over the years there have been many studies and experiments to study impulsive behavior and why some struggle with it while other do not. Through imaging healthy individuals and impulsive patients why they do certain exercises it has been determined that most of the control of impulsive behavior occurs in the frontal lobes. The specific neurotransmitters involved in the process have also been identified. Once this was figured out scientist have been able to alter these transmitters in people and cause impulsive behavior in otherwise non-impulsive individuals. 

There was a study done where several healthy individuals had there frontal lobe neurotransmitters manipulated to create impulsive behavior. The scientist told each of the patients that they would walk down a hallway and turn to the left and on a shelf they would find money. They were instructed not to take the money and they all agreed not take the money. The study group with the altered neurotransmitters nearly all took the money even though they said they would not and had agreed to not take the money. The control group had no problem not taking the money. They left the money alone. In the same experiment patient with impulsive behavior disorders almost always take the money. In the interview with the normal patients who had their neurotransmitters temporarily altered for the experiment could not explain why they took the money. They knew that they were not supposed to take the money and had planned on not taking the money but somehow when they saw the money they acted without any control. 

Also when you study teenagers brains we see on imaging studies that their immature brains lack the full ability and neurotransmitter stability to inhibit impulsive behaviors. We also know that alcohol disturbs the balance of the neurotransmitter necessary to inhibit impulsive behavior. In thinking about evolution you must ask why has impulsive behavior survived all these years if it is detrimental to humans. There must be a protective aspect to it or we would not continue to have the impulsive behavior. All healthy brains have the ability to modulate the neurotransmitters in such away that they turn off the inhibition center allowing impulsive behavior to flow freely. This is protective in many circumstances. For example in times of danger like hitting black ice while driving we are able to act without thinking, we impulsively steer the car out of the spin and in the proper direction often preventing disaster. When things like this occur our inhibition center for impulsive behavior is turned off or less active allowing for the protective impulsive behavior to take over. There are many more examples of situations where a person may need impulsive behavior for protection. 

Everyone has times in their life where they may act impulsively in a good way and sometimes in a bad way. I know I have had times in my life where I said or did something only to wonder why I could not control myself in that situation and I vow to not make the same mistake in the future but then in that same enviornment in the future I make the exact same error again and again. Eventually I learn to control this or avoid the environment. I do not have a disorder or at least I have not been diagnosed with an impulsive behavior disorder and I can't imagine how difficult it must be for someone who has severe pathology leading to impulsive disorder.

This all leads to a question? Does an individual who has pathology in the inhibitory center for impulsive behavior have the ability to control these impulsive behaviors? Does he/she have free will with regards to these specific impulsive behaviors? 

"Out of my mind"

I have a new appreciation for the phrase "out of my mind". Today I had a 29 y/o female that was admitted for extremely bizarre behavior. She lives in a motel and the neighbors reported that about 4 weeks ago she "flipped out" and has been acting strange ever since then. The latest that landed her on the psych ward was she was walking the halls naked and trying to engage in sexual acts with neighbors and anyone who came within her vicinity. We call this hyper-sexual. 

I tried to interview her and she was in frank psychosis. She had disorganized thoughts and flight of ideas. For example: 

Me: Do you know why you are here? 

Patient: Here? why is there a light on the ceiling I am a child. 

Me: Have you been using drugs? 

Patient: Drugs? no, no, no, no, no, who is the dealer the man can sing about a snake undone promises I hear you. 

It went on like this for nearly 30 minutes. This is a psychotic break and they are very interesting and fascinating. 

I started her on some antipsychotic medication and she will probably return to some level of functioning in the next couple of days. She will not remember any of these details. We have to figure out what her diagnosis is for sure. She looks like she has schizophrenia, disorganized type but it could also be a substance induced psychosis. 

This is what you call being "out of your mind".

Snap, Crackle, Pop

Over the weekend we were on call and we got slammed. It must have been something in the air or the water because we got 16 new patients into the lock down unit. One of the patients was a medical mystery that I was able to help the medicine team solve it. 

This was a 32 year female who is married with 2 sons, 9 year old and a 13 year old. In January the 13 year old was diagnoses with lymphoma and things became too hectic for her. She and her husband are struggling financially and they live with her family in an apartment. She feels like her mother, father and siblings are critical of her parenting. She is sensitive to their comments and really feels like a failure. She and her husband have been arguing a lot about the care of their 13 year old. They have differing approaches and this causes a ton of tension. the 13 year old with lymphoma is progressing in his treatments and his survival chances look good but he is bald, and can't play any sports and basically really pissed off with life. This is hard for the mother to watch and she feels guilty about the situation.

This past Thursday she was at the end of her rope and after an argument she downed a bunch of Ibuprofen and got into bed. If she had taken tylenol I would not be writing about her because her suicide attempt would have most likely been successful or at least put her in the intensive care unit. Her husband suspecting something was up questioned her about how many tablets she took. She refused to answer and went into the bathroom and forced herself to vomit. She went to sleep without any problems and woke up the next morning and went to work. While at work she had a lot of chest discomfort and pain and ended up coming to the ER. They ran all kinds of tests to rule out cardiac issues and could not find anything. The husband came in and told the doctors that he thinks his wife swallowed a bunch of ibuprofen and then her doctors called a psych consult.

Friday I went to see her on the medical floor and had her tell me her story. When I placed my stethoscope on her chest to examine her I felt a crunching and popping sensation. I noticed that she had air bubbles under the surface of her skin around her mediastinum. This is something called Hammond's Crunch and it is usually caused by a perforation in the esophagus. You can see this in bulimics  and alcoholics from vomiting. I asked her about recent vomiting and she confessed to vomiting up the ibuprofen and that it was a rather strong retching that took place. I put the clues together and called her medicine doctor and he was glad to hear the details because he had been worried about what was causing the chest discomfort. 

Her medicine doctor ordered a gastric / esophageal imaging test to see if there was a perforation and a small perforation that was now healing was detected. She did not need surgery and her doctors cleared her medically now that they knew what her condition was and how it was progressing. We were set to clear her from a psychiatric stand point as she seemed relatively stable and denied and suicidal ideations. We created a safety plan which included daily therapy and wrote some medications and set her up for discharge. However after we left she broke down again and locked herself into the bathroom. We were called back to see her and we quickly determined that she needed to be admitted onto the psych unit for further evaluation and monitoring. So we admitted her and I was assigned to her case. 

This is one of my 5 new patients over the weekend and they are all fairly interesting like this case. That is one thing I like about psychiatry, a lot of the cases are intriguing.

Crisis Intervention

Today I was assigned to the crisis team in the emergency room. This is a group of psychologists and social workers who handle all the counseling aspects of acute crisis. If their is a trauma that requires talking with the family of the victim, any violence, death, suicide ideations, drug intoxications, rape etc, the crisis team handles all the counseling. I was assigned as their medical / psychiatric consultant. My responsibility was to evaluate the patients from a medical perspective and handle all the medication management. I had an emergency medicine attending doctor to report to but he basically let me run my own show. 

We had a busy night. I had 2 panic attack patients, 1 drunk driving accident, 2 suicide attempts, 2 drug / alcohol over doses (not intentional) and a couple traumas. I love the emergency room. It is fast paced, go, go, go! The time goes by quickly and you feel like you are making a big impact on patients' lives in a very vulnerable time. I had to call family members to report bad news. A couple of the patients I ended up admitting into the psych ward and my psychiatry attending doctor was on call so these patients will be mine to follow in the inpatient unit as well. This will provide great continuity of care. 

One thing I notice in the emergency room and in the hospital in general is that there is a ton of dysfunction in the world. These patients are often on drugs, in abusive environments, lonely and out of control. They often have no guidance in their lives and very little education. They bring a lot of disaster into their lives through the choices they make and often these choices land them in the hospital. It is sad to see all the dysfunction and miserable individuals suffering. It is especially difficult when a young child is exposed to their parents chaos and end up being a victim. The dysfunction grows and is often passed from generation to generation. 

The question is; how do you help one of these patients break the cycle of dysfunction?  

The baby momma is back

If you read a few posts back I had a patient that was a homeless mother who gave birth and tested positive for drugs and when the hospital staff took her baby and gave it to DCFS she went haywire. She punched, kicked, screamed and became a danger to herself and the staff. She had a full fledge temper tantrum like you see in a 3 year old, but she is 18. Eventually custody the baby was given to the patient's mother. The patient was not happy about this, as she had a long history of discord with her mother. It was also questionable if the patient's mother was capable or a fit mother.

She was quite the handful on the psych ward and ultimately I was able to piece together her psychiatric history. She had long standing bipolar (real bipolar) with mania and she was in the middle of an acute manic episode that actually began prior to giving birth. Her mania was so strong that she did not sleep for 2 weeks and she required no pain medications during the birth. She was unbelievably strong and required 5 + men to restrain her. 

I medicated her and got her back on a regimen that would treat her bipolar illness and it was amazing to see her improve over the course of several days. She transformed from a manic tyrant that was completely out of control and was in and out of reality to a relatively regular immature teenager. However there was no doubt that she has actual bipolar manic disorder and without medications she will end up in a psychiatric hospital. 

On the day of her discharge I was worried that she would head straight to her mothers and demand to have her baby back and cause all kinds of problems. However we could no longer hold her on the psych ward because she had improved and was no longer deemed dangerous to herself or others. She maintained that she would not cause problems with her mother and that she would work through the courts to get her baby back. 

Well she is back and she is my patient again. She was brought to the hospital by the police and she had several altercations before landing here in the hospital again. I had to sedate her this morning because she was yelling and screaming and attack staff and other residents all while being nude. It was quite the scene.

Consultation and Liaison (C & L)

Today I was assigned to the Consultation and Liaison team. This is a service offered by some psychiatrists that serves the general medical and or surgical inpatient patients. For example, if a surgeon has a patient in the hospital recovering from a surgery and it is noted that the patient has been making suicidal statements or has anxiety or is overly depressed, the surgeon will request a psychiatric consultation for that patient. The C & L psychiatrist will then come and see the patient and make recommendations for that patients mental health. Sometimes the recommendation can be that the patient needs to be admitted to the psych ward and sometimes it is just a simple psychotropic medication adjustment. 

Often the C & L team is called to clear a patient psychiatrically for discharge from the hospital. I like this type of psychiatry because it is very involved  in the medical aspects as well as the psychiatric aspects. You must understand the patient's medical condition and how it applies to their psychiatric status. Today we saw lots of interesting patients. Some of the patients were quick psychiatric evaluations where we determined that the patients were fine from a psychiatric perspective. A couple of patients required an involuntary admission into the psych unit. This is required if the patient is considered dangerous to him/herself or others. 

There is actually a fellowship program following a psychiatric residency in C & L. It is a one year program where you focus on all aspects of the medical and surgical patients with regards to their mental status. However this fellowship is not a requirement to practice as a C & L psychiatrist. Any psychiatrist can offer this service but only some wish to be involved with this service. One of the things I do not like about psychiatry is that it is so focused on the mental health of the patient that the psychiatrist loses their medical knowledge to a certain degree. I really like the medical and surgical aspects of my training and I would hate to lose those skills over the upcoming years. For example, a seasoned psychiatrist often will be completely clueless on the current practice of treating pneumonia, or diabetes or even CPR.  This is also true of many of the other specialties as well, like a dermatologist will become lost when it comes to illnesses outside the scope of the skin. Many psychiatrists and other specialists are happy to unload these skills and just focus on their specialty. I guess you have to focus to some degree in order to become an expert in your given area but there are plenty of specialties that require a broader knowledge base of the entire spectrum of diseases. 

A tummy Ache

This case was unrelated to my psychiatry rotation but I was required to write it up and present it / teach about it to the other medical students. To read this case please scroll down to the April 1st post below. I have included some images here but the written post is below. You can click on this link to go directly to the case:

http://jjmedicalschool.blogspot.com/2009/04/currant-jelly-stool.html

Bipolar What?

I have been seeing a ton of bipolar on the psych ward this week and last week. The director of our psych ward is a well seasoned psychiatrist with 30+ years of practice experience. He also sits on the board for the DSM which is the bible of diagnosing psychiatric illness and is a professor at one of the local medical schools and highly regarded in the field.  He is very interested in  bipolar disorder and has published many different papers and studies on the illness. What I am saying is this is the perfect guy to have as a mentor / teacher of  bipolar and everything else in psychiatry. 

What is bipolar and why is there so much confusion about this disorder? Why is there so much misdiagnosis in some populations and under diagnosis in other populations and finally over diagnosis in some populations? Oprah and the media have highlighted bipolar on their shows which has caused people to stream into their doctor's office thinking that they might have bipolar too. Today we had a big conference with the residents and attending physicians where we discussed bipolar as a psychiatric illness at great lengths. I will attempt to discuss the very basics here on the subject. 

You have Bipolar 1 and Bipolar 2. What are the differences? Bipolar 1 is a major manic episode with or without major depressive disorder. The patient with Bipolar 1 has to have had 1 episode of mania and that is it. It is irrelevant if he / she has depression. Now what is mania? Here is where all the confusion and debate comes in on the subject. The majority of psychiatrists believe that in order to classify an episode as true mania the patient has had to lose touch with reality and end up being hospitalized due to the mania. SO if I present a patient that sounds like mania yet it was not severe enough to land that person in the hospital they would tell me that it is not bipolar 1. Most patients with bipolar 1 are actually diagnosed when they end up in the hospital after their first real manic episode. The many bipolar 1 patients I have been working with on the psych floor are acutely manic and forced into the hospital. It is very apparent that they have lost touch with reality in many aspects of their life and suffer from various delusions. They claim to have jobs that they have never in fact had.  They really believe that they are the CEO of a major corporation or the head coach of a major league sports team. Every patient I have seen has been awake for nearly 1 week without sleep which is another sign of true mania. It is interesting to note that most patients do not recall their behavior or the events that took place during their manic episodes.  Most bipolar patients experience devastating consequences of their manic behavior including being arrested for violent behavior, losing their jobs, drug use, and extreme and risky hyper-sexual behavior like unprotected group sex.  These behaviors are indicative of bipolar 1 and and must be present in order to definitively diagnose bipolar 1.  

Now what is Bipolar 2? Bipolar 2 consists of at least 1 or more major depressive episodes and and at least 1 or more hypomanic episodes. If the patient has ever had a true manic episode then they can't be considered for bipolar 2. Simply put Bipolar 2 is major depression with hypomania. What is hypomania?  Basically hypomania is a dialed down version of true mania and does not end up with a psychiatric hospitalization. The patient has not lost touch with reality and not experiencing the delusions as seen in true mania. Nevertheless hypomania is not an episode of excitement that all people experience at different times in their lives. The episode is prolonged and much more intensified that the normal excitement we feel on a normal basis. Imagine the excitement you had as a kid around Christmas but now amplify this to the point where you have some seriously inappropriate social behaviors like grabbing your assistance behind in a hyper-sexual fashion  and then stretch this feeling out for 2 weeks straight and you start to get an idea of hypomania. Hypomania is not a mild situation and often lesser episodes or excitement are mistakenly called hypomania. The other confusing part of Bipolar 2 is that the patient must have experienced a major depressive episode as well. Again people confuse regular sadness or mild depression with major depression and then make an incorrect diagnosis.

Given this info it becomes clear how so many can be called bipolar when in fact they are not really at that level of disease. At the conference today, the doctor explained that true Bipolar is near, or on the same level, as schizophrenia. It is not a mild diagnosis. However in some populations it is a popular albeit incorrect diagnosis. For example you have a fairly regular patient who experiences anxiety and some mood changes with some inappropriate social behavior and some mild depression. Many diagnosis this as Bipolar when in fact the patient does not have a true mania or a true major depression. Most likely they have some generalized anxiety disorder with mild depression.

Now here is the kicker as explained to me today. Most psychiatrist know all of the aforementioned info inside and out yet many still make incorrect diagnosis of bipolar all the time. Why you ask? Answer = money. In order to get paid for certain medication management and clinical work, the patient must have a diagnosis that warrants aggressive medical management or the doctor will not get paid or will get paid much less. This happens in other fields of medicine all the time. In dermatology, in order to get paid for certain surgery a specific diagnosis of a condition must be made regardless of whether the condition actually exists. The insurance companies have created so many hurdles to get paid for your work and these misleading and incorrect diagnosis are unfortunately the result.

Who cares? Why make a big deal about all of this? Well the treatment of bipolar includes some heavy medications with serious long term side effects which a patient should not be exposed to if they do not need to. These are not minor side effects, and it can take time for the side effects to develop and may be irreversible.  In contrast, the treatment for generalized anxiety and milder forms of depression do not use these big gun mood stabilizers you see used in bipolar. Ironically a patient with generalized anxiety disorder and or mild depression will often see improvement while on these bipolar medications but unfortunately are exposed to levels of toxins that they do not need to be exposed to.  They can see the same level of improvement, if not better improvement, with other milder medications that target generalized anxiety disorder and or depression. I have not even brought up the social implications or stigma of being diagnosed with bipolar, and when it is an incorrect diagnosis a patient will needlessly suffer from these social issues as well.

Psychiatry is complicated. Unfortunately there are no blood tests for most of the psychiatric illnesses, and diagnosis can often be nebulous at best. A well versed psychiatrist can make nearly any disorder or syndrome sound like another or different syndrome if they so desire or take relatively normal behavior and stretch it to look like a disorder if there is some benefit in doing so.  At the same time, a truly gifted psychiatrist who follows his / her hippocratic oath can usually accurately make correct diagnosis for all of the psychiatric illnesses.  

The patient must be their own advocate or have a family member that can advocate for them, and 2nd and 3rd opinions are never a bad idea.   

We will take the baby

One of my patients is a 18 year of girl who recently gave birth to a baby boy. She had no prenatal care and was never seen during her entire pregnancy. She spent a portion of her pregnancy on the streets. She entered the hospital to give birth and upon giving birth the ob/gyn ran a tox screen on the mother and the baby. The tox screen was positive only for marijuana for both the baby and the mother. So they took the baby and turned it over to dcfs. Upon learning this the mother became severely agitated and attacked several staff members. She punched, kicked and screamed for hours. She was admitted to the psych floor directly from the maternal ward. I was assigned to her to manage her treatment.

I went into her room to introduce my self. Upon saying "hello" she immediately started shouting saying "give me my mother blanking baby right now you mother %&%$&!" She preceded to get out of the bed and tried to engage me in a fight. Fortunately I had no interest in sparring with the patient so I excused myself and ordered up some medications for her. After a while she was more sedated and I was able to examine her and get a history. 

This girl has had a long and hard life and she is only 18 years old. As a young girl she was molested and raped numerous times by her mother's different boyfriends. She spent time living with her mother on the street and eating from garbage cans at the age of 3 to 6. Her mother was in and out of apartments and shelters. Her mother had a psychiatric history of mental illness and drug abuse. By the time the patient was 12 years old she had become exceedingly difficult to manage and her mother could not handle her. Her mother dropped her off at a child / teen psychiatric residence in the suburbs where she became property of the state. The patient lived in the state facility from the age of 12 - 18. 

Her first pregnancy was at 14 but she lost the pregnancy under questionable circumstance possibly a self induced abortion or street abortion. She was diagnosed as Bipolar / manic by a psychiatrist and treated successfully in the state facility. About 1 year ago she turned 18 and left the facility to live on the street and in various shelters. She quit taking her medications and began abusing drugs and practicing prostitution. Ultimately she became pregnant and spent the majority of her pregnancy on the streets. She went into labor last week and was taken to the hospital to deliver. After the delivery and prior to the tox screen the staff noticed that she was abnormally excited / manic. 

She was put in our psych ward and was very difficult to manage, requiring restraints and medication to sedate her. She attacked staff and other patients. She was remarkably strong. I was able to interview her in the peak of her mania and she explained to me that she had not slept in 'weeks". Her speech was very fast and she jumped from idea to idea very rapidly. She also explained to me that she had super powers and could control people with her thoughts. She felt because of this she was above the law. She was also very agitated. 

These are common signs of mania. Many people think that mania is being excited and having a sense of euphoria. However in all the cases of real mania I have seen there has been a break with reality. Some of the psychiatrist I am working with require this loss of reality to really call the episode mania. Others are more lenient with the term. I am of the thought that true mania presents like this patient with pressured speech, severe agitation, grandiosity, no sleep, and loss of touch with reality. My mentor told me today that most true bipolar patients will be diagnosed once the patient is forced into the hospital involuntarily. She also is leery to diagnose true bipolar without this type of hospitalization. In other words for a true diagnosis of Bipolar one of the signs and or symptoms will be involuntary hospitalization. I would say that this is what I have seen so far as well. The mania in these patients is so out of control that they loose touch with reality and ultimately find themselves in a psych ward extremely agitated. Usually they can't remember the incident once they come down.

The amazing thing with my patient was that once I was able to medicate her she became a whole different person. She transformed from so type of feral tasmanian devil to a nearly normal 18 year old teenaged. She became very polite and realistic about her situation. She was no longer agitated and was and actual talked of getting herself togther so that she could become a good mother. I think that if she continues her medication and remains off the streets she has a very good chance of ultimately regaining custody of her child. We are preparing for her discharge after some more observation. We have had her on the unit for nearly 1 week and the transformation has been incredible.

Psychiatry Lock Down

So I started psychiatry rotation this week and it is crazy.. no pun intended. I am working on an inner city psych ward that is locked down. Most of the patients are there or at least put there involuntarily. These patients are fairly sick and represent some of the most severe mental illness pathology that cane be seen.

Walking onto the ward you immediately notice a variety of foul smells. Patients in soiled gowns with poor hygiene make for interesting smells. You also notice people with blank stares roaming aimlessly through the hallways. Every so often you will hear an eruption of emotion. Someone will yell profanities at the wall or at an imaginary person that no one cane see. Occasionally a patient will need to be calmed down and fortunately we have a large staff of trained security that is ready to jump in at any time. 

I am currently assigned to 3 patients that were admitted this week and I work with another 6 that are assigned to my team. One of the patients is a young 28 year old man who was diagnosed 3 years ago with bipolar when he had a manic episode that left him awake for 3 weeks straight. During this time he completely lost touch with reality and dropped out of his masters program. He took all of his money and all of his student loans and jumped into his car to report to spring training in Arizona. He was convinced that he was recruited to start for a major league baseball team and he needed to be at spring training. He had never played a day of baseball in his life. Prior to this episode he had had some issues but was never treated for any specific illness.

After 3 weeks of running without sleep he was arrested and charged with trespassing when he was trying to enter a high-school stadium in Arizona at 3 in the morning. The policed realized  that they were dealing with someone who was not quite right so they took him to the hospital where he was admitted and ultimately treated for his mania. This was 3 years ago. Now fast forward to this week. 

Now this patient moved to Chicago a year ago to work as at a successful accounting firm. Ha has been well managed on his medications and has been doing well. About 1 week ago he started acting a little funny his brother thought when he would call. HIs brother lived in another state and reported that he thought his brother may have stopped taking his medication because he seemed to be a little manic and not quite right. His brother was right. The patient stopped his medications 2 months ago and had become increasingly manic until about 1 week ago when he completely lost touch with reality and again took all of his money and bought a brand new car that he could not afford and went on a week long binge of rock star tyoe activities that included gambling and dance clubs where he celebrated his new promotion as CEO of the company but unfortunately there was no promotion.

His brother flew out from another state to track his brother down but his too late. His brother had been arrested for attempting dance naked in the lobby of a major corporation where he told everyone that they were fired and he was the new CEO. The police brought him to our unit and I was assigned his case. Day 1 he was flying high, unbelievable mania. Hi tox screen was clean so there were no drugs of abuse affecting his mood. He had unbelievable energy and was very happy explaining that these were the best days of his life and that he was the new CEO.

More to come.

Currant Jelly Stool

Intussusception Currant Jelly Stool  

This is a case I had and when the director of pediatrics heard about it I was asked to write it up and present it in lecture format to the 1st and 2nd year medical students. I thought I would share it here as well.

So the other night I received a call from a patient's father who explained to me that his 10 month old was not feeling well. He had diarrhea and currently no fever but had a fever earlier in the day of 101. The father had some questions about what could be the cause of the diarrhea and what to do about the diaper rash that had ensued from all the diarrhea and diaper changes. My initial gut felling was that there was something more to this case but I did not want to panic or cause panic of any kind. So I told the father how to care for the diaper rash and gave strict instructions to call if things got worse or if another fever developed. I know this father and I was sure he was a capable caregiver and a responsible parent.

The next morning while I was in a psychiatry lecture I received a call from the same father and this time there was a little more concern in his voice and he said I think that I can see blood in the stool and he told me that the diarrhea had continued through the night. I immediately recalled the uneasy feeling I had about this case the night before. Now armed with this new symptom, I asked the father to describe the blood and he explained it as a mucus like blood in the diaper with the stool. I immediately had a few good ideas of what this could be but without seeing the diarrhea and blood or the actual patient it was hard to say for sure. Many things could potentially cause these kinds of symptoms. I told the father that I thought it could be intussusception or maybe a bacterial diarrhea but that I needed to see the stool and the blood.

I asked the father to take a picture of the diaper with the stool and the blood and email it to my phone. He said he would do that and hung up the phone. About 2 minutes later I received the picture via my email on my phone. As soon as I opened the picture I had my diagnosis mostly nailed down. It was easy to see in the picture that the blood was a thick currant jelly like stool which is what is often seen in intussusception. There it is was (currant jelly stool) in the digital photo calling out to me. I immediately called the father and said you need to go into the hospital or to your doctors office immediately as this would require treatment. There was no way for me to know for certain through a picture and a phone call that it was intussusception for sure but I felt fairly certain that this seemed to be the diagnosis or less likely a bacterial diarrhea but either way treatment was necessary and if it was intussusception then it would require immediate treatment to prevent bowel necrosis and tissue damage.

After hanging up the phone and then again texting the father to reiterating the urgency of the situation I went back to the lecture I had been attending with the picture of the soiled diaper still fresh on my phone. A friend of mine looked at me and seemed to ask me with his eyes "what is all the commotion about". I approached him and said take a look at this picture and tell me what you think the disease might be. He is very bright so I was interested to see if he agreed with my diagnosis. He took a look at the picture and immediately said "first of all the picture is disgusting and second of all I think it is intussusception". I was glad he had the same thoughts because at this point the father was already on his way in to see his pediatrician. This friend of mine had done his pediatric rotation with me and we had seen a couple of cases of intussusception on our rotation. In addition to my pediatric rotation I had seen a few more cases while working on my emergency medicine rotation in the pediatric ER.

Later in the afternoon I got a call from the father and he said that he took his infant into the hospital and they confirmed that the diagnosis was in fact intussusception. I was elated to know that all this studying and working was seeming to work. Often you can miss a diagnosis so it always feels nice to get them right. However I was still concerned for the infant.

What is intussusception? Basically the intestine telescopes within itself like it is trying to digest the intestine itself. When this happens the blood supply can be cut of to the affected portion of the intestine and if it is not treated and fixed the bowel will begin to die and necrosis will set in. Essentially the intestine becomes blocked. Intussusception is considered a medical emergency for this reason and if left untreated a child can die with in 3 - 5 days or have significant loss of intestine due to necrosis. It is diagnosed officially and treated with the same process. Most hospitals use either an air enema to blow the telescoping intestine back out of the intestine it has gone into or a barium enema can be used to visualize and fix the intestine by pushing it back to its original location. In roughly 80% of the cases this is all the child needs and can be discharged home with instructions to rest the bowel (no solid foods) for a few days. 10 - 20% of the patients can have a reoccurrence of the intussusception and or those that reoccur 85 - 90% reoccur within the first 24 hours.

If there is a reoccurrence then a surgeon will surgically move the intestine back into place and may secure it so that it will not telescope again. In a small number of re-occurrences the surgeon may need to cut out a portion of the intestine. Classically the patient will present with the currant jelly stool and will be between the ages of 5 months - 1 year but sometimes the patient will not have the currant jelly stool and can be much older like 5 years old or even older. These atypical cases can be tough to figure out an the patient is at a higher risk of a delayed diagnosis and higher risk for loosing intestine due to necrotic damage.

The infants themselves will present with diarrhea, sometimes vomiting, crampy abdominal pain and abdominal tightness and fever. A good doctor may be able to feel the intestine portion that is blocked and it feels like an encased sausage. This can be a difficult diagnosis because the infants can't tell you what is wrong and where they hurt. They are just generally fussy and miserable.

How common is intussusception? The statistics state that there are about 1 - 4 cases per 1000 infants. Some areas may see more of this than other areas, so some pediatricians may not see it very often while others will see it more commonly. A few years ago the first rotavirus vaccine was thought to increase the incidence of intussusception so there were more cases popping up. The vaccine has since been replaced with a newer version that does not increase the incidence.