Detox Diagnosis--Keeping Medicine in Psychiatry

(The following are case studies discussing the impact of proper evaluation of comorbid psychiatric illness and medical disorders. To read more case studies and find out how to effectively recognize and treat patients with these disorders, please see the January 2002 issue of Psychiatric Times pp49-54--Ed.)

Case 1History. A 52-year-old Asian American gentleman was admitted to the inpatient psychiatry service to "dry out" following a drinking binge. At morning report, the addiction treatment team reported that the patient claimed, "belly discomfort during the night with no relief from antacids."

Physical Examination. Exquisite right upper quadrant stomach tenderness was noted at bedside exam.

Imaging. Stomach X-rays (films) were performed prior to the hospitalization on the inpatient psychiatry service. The radiologist stated that the calcification visible in the right upper quadrant belly film was "a pill."

Consultation. The chief of surgery was consulted for a second opinion, and he diagnosed a gallstone rather than a pill. Upon bedside examination, he diagnosed acute cholecystitis and ordered immediate intravenous antibiotics, intravenous fluids and cholecystectomy. The patient said he appreciated the timely and definitive diagnostics, treatment and care. He added, "Doctor, I was told I had a sick gallbladder with a gallstone years ago. I was advised then to have my gallstone and my gallbladder taken out surgically, but I did not get it done." When asked why his previously recommended gallbladder surgery had not been performed, the patient answered, "Different reasons, Doctor. First my doctor died; then my car died; then my dog died; then I lost my insurance; then I just lost my nerve, and I was afraid to have the surgery. Doctor, I guess the major reason was that I just could not stop drinking long enough, and I could not ever dry out long enough to have my gallbladder taken out." Twelve-step work with sponsorship was recommended, and the recommendation documented, for him to develop and use his Tools of Recovery.

Critique. When a step-by-step review was initiated to ascertain how our patient with an acutely inflamed gallbladder came to be hospitalized on our detoxification unit, we learned that the findings of the patient's medical physical examination were initially unimpressive; that is, his stomach was soft, with no guarding, tenderness or rebound tenderness. However, as his blood alcohol level dropped and he became more alert, the findings from his medical physical examination changed. The core issue would appear to be that the willingness to provide repeated medical physical examinations at the bedside leads to the correct diagnosis, and thus reasonably timely treatment and care of the underlying and previously ignored medical issues.

Case IIHistory. An 85-year-old white gentleman was admitted to the inpatient psychiatry service to "dry out" following a drinking binge. At morning report, the addiction treatment team said that the patient was "sleeping it off."

Physical Examination. At the bedside, I observed the patient to have a pulse of 120 beats per minute, a respiratory rate of 40 breaths per minute, and to be in a semi-coma, from which he could not be awakened.

Emergency Consultation. The medical intensive care team was called. With correction of his fluid and electrolyte imbalance and stabilization of his pulmonary status, the patient woke from his semi-coma and was returned to our inpatient psychiatry unit, where he remained comfortable and stable until our social work service could provide comfortable alcohol-free housing for him. He verbalized his appreciation of our timely diagnostics, treatment and care and also for our human services liaison. Twelve-step work with sponsorship was recommended and documented for him to develop and use his Tools of Recovery.

Critique. In a review of how this patient came to be hospitalized on our detoxification unit, it became apparent that his first medical physical examination was performed on the morning after he arrived on our detoxification unit. Records documented previous detoxification unit hospitalizations; at this repeat hospitalization the patient appeared in a reasonable disposition. The only glitch was that in the middle of the night the patient was minimally examined, if at all; and, in the absence of a complete medical physical examination, was simply labeled as a patient who was "sleeping it off." Once the pulse rate, respiration rate and level of consciousness were determined on the detoxification unit, then an accurate diagnosis of semi-coma became much more clear. It is probably a good and reasonable diagnostic rule-of-thumb that the majority of hospital inpatients, whether chemically dependent or not, need a thorough medical, physical examination by their health care providers on morning rounds.

These two case studies are representative of the many reasons why health care providers need to put aside typical stereotypes and tunnel vision and provide our chemically-dependent patients with the same care as our non-chemically dependent patients.

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