WILTIMS #310: Sometimes, just ask

I actually did something productive! I was joking on Tuesday that my only helpful attribute was being male so that I could check the bathrooms for the missing veteran (who has since been found BTW). Well today, I finally did something useful in my capacity as a medical student. It was reported by the nursing staff in morning report that a normally compliant patient refused to take his medication last night. This came as a bit of a disappointment to the medical staff as we had had a very pleasant meeting with him the previous day about reducing that medication but in a safe, controlled way. As my supervising doctor was very busy this morning with some new admissions, I was given the task of interviewing the handful of his patients that I'm familiar with, one of the goals being to figure out why the patient had refused his meds. A common reason on a psych ward is a paranoid delusion that the meds are doing something other than what the doctors/nurses say they're doing.

The answer turned out to be very simple. I asked him why he refused the medication and he very reasonably explained that the nurses were giving the medication later at night than the patient was comfortable with. All it took was someone (like me!) to ask and for the doctor to schedule to medication at the evening dispensary time instead of the night one and we were good to go.

I know this is a tiny action and the mystery would definitely have been solved by someone else if I weren't there, but it still felt nice to be actively involved in improving a patient's care.

This case actually has another interesting point. The medication was at the center of our efforts to pin down what was ailing the patient. He had been on this med for years, but we are concerned that it may be treating a condition he doesn't have. So we began weaning down the dose to see if one of three things happens:

1. The patient gets worse, showing that the meds were doing something right
2. The patient gets better, showing that the side effects were severe
3. Nothing happens, showing that the medication wasn't doing anything and should be discontinued

TIL: Don't prescribe benzodiazepines to recovering opiate abusers as both drug classes depress respiratory function and if the patient falls off the wagon, they risk life threatening drug interactions.

Double depression is a term for when a patient with dysthymia (chronic atypical depression) develops a major depressive episode as well.

WILTIMS #245-8: Mega-post 2 - The Revenge

Friday: Today I got to give another presentation about the science behind smoking and lung cancer at a local school for a club that I'm involved in at our school. Compared to the very upscale middle school at which we had previously presented, this was a much rougher school in a poorer neighborhood, but I think I had even more fun and had a better chance of making an impact.

FridayIL: Though they can cause sedation, benzodiazepines cannot cause full blown anesthesia or coma.

MondayIL: Subarachnoid hemorrhage is most often caused by "berry" aneurysms. These are little berry-like bubbles that sometimes form around the junctions between the blood vessels of arteries in the circle of Willis in the brain. They weaken the vessel walls, much like if you poked into a balloon with your finger, causing a thinner, finger-shaped bubble to protrude from the otherwise normal balloon. If the balloon were ever going to pop, it'd pop in that thin bubble.

Tuesday: Snow day!

WednesdayIL: Bupropion (Wellbutrin) is an antidepressant that is also used to aid in smoking cessation. Patients were so upset by seeing that they were being prescribed an antidepressant, even if it was for a different indication, that the company started producing the same drug under a second name (Zyban) so that people would take the prescription without worrying about the stigma of being on antidepressant medication. What does this say about our society's feelings on mental illness?

TIL: If a brain lesion causes a gaze preference (someone's eyes skew to one side at rest), you can usually differentiate from symptoms caused by ischemia (loss of blood flow) or seizures. If ischemia is the cause, then the patient will look toward the side of the head that the lesion is on, whereas seizures cause the patient to look away.

Hemorrhagic stroke often causes headache and lethargy, whereas an ischemic stroke does not.

Seizures can confusingly cause the symptoms of a stroke, like muscle weakness, in the hours and days post seizure.

For carotid stenosis (hardening of the arteries supplying the brain due to athlerosclerotic plaque formation) the original treatment was to cut open the neck and carotid artery to physically scrape out the plaque on the artery walls - this is called a carotid endarterectomy. Once stents were invented everyone hoped that it would be a great, less invasive alternative to the major surgery that is the endarterectomy. But they quickly realized that the act of placing the stent increased the risk of breaking off a part of the plaque and causing a stroke - exactly what we were trying to prevent in the first place. So now, surgery is the first line treatment again and stents are only used if surgery is contraindicated.

Oculus uterque means "both eyes."

WILTIMS #123: Oh, behave! (-ioral science)

Today I had my first behavioral science case conference and it was one of the most captivating experiences I have had yet in med school. A quarter of our class (about 50 students) decked out in our white coats filed into a small room in the behavioral health center at the nearby hospital and watched our professor interview an actual psychiatric patient. I won't share any specifics due to patient confidentiality but I think we were all surprised by the level of delusion we witnessed today.

Some thoughts from that session:

• When interviewing a possibly psychotic patient you must always remain calm and understanding. The patient will be watching to see if you can handle the story they're telling before they are willing to reveal everything.
• When appropriate, only challenge the delusion once - just to see how solid it is. Then back off and regain the patient's trust. Challenge in this case means merely asking if the patient has ever doubted that the delusion is real - not yelling at them or anything truly confrontational.
• You must be careful about your emotions when dealing with medication non-compliance. Whereas it might be frustrating with other more physical medical problems, remember that non-compliance is actually part of the illness with psychiatric disorders.

TIL: Deer Hunter is a messed up movie. I'm pretty sure our professor wanted to teach us about PTSD by giving us PTSD using the most disturbing parts of this movie.

If a person with depression has one manic episode ever, then they are diagnosed as having a bipolar disorder.

Generally, bipolar patients who are undergoing treatment maintain the same level of symptoms throughout their lives while schizophrenic patients progressively decline.

1 in 7 people with untreated depression and 1 in 5 with untreated bipolar disorder will die from suicide. There is an emphasis on untreated here, but these numbers are still frighteningly high.