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.
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