Detox Diagnostics -- Keeping Medicine in Psychiatry

It has long been known and generally appreciated that psychiatric diagnoses can be established in medical and surgical special care units and in the general medical and general surgical patient populations, both in hospital units and in ambulatory care settings. The impact of comorbid psychiatric illness on medical disorders is reasonably well-appreciated (Glassman and Shapiro, 1998; Musselman et al., 1998). Is the reverse also true? Need mental health care professionals remain vigilant to identify and address general medical and surgical issues in psychiatry units?

The following vignettes briefly review patients admitted to the inpatient psychiatry unit with either alleged acute psychiatric conditions or to "dry out" but who were in urgent need of timely medical and surgical interventions. (To read more case studies, please refer to the Psychiatric Times Online Exclusive article at www.psychiatrictimes.com/detoxcase.html--Ed.)

Since we know cholelithiasis with cholecystitis, respiratory failure and malignancy to be common disorders in our general patient population, and we know that our chemically dependent patients are representative of our general patient population, then we can reasonably expect to see these potentially serious and potentially life-threatening (yet readily treatable) disorders in our chemically dependent patient population as well. When we, as health care providers, are willing to give up, rescind and/or withhold the label of "alcoholic" and/or "addict" and focus our bedside history and physical examinations on our chemically dependent patients, just as we have always done on our medical and surgical patients, then we can be empowered to provide comprehensive, high quality care. While we recognize the increased percentage of chronic hepatitis B, chronic hepatitis C and (chronic and acute) AIDS in our chemically dependent patients and the need for specific testing and appropriate treatment and care, I present the following cases to raise the index of suspicion on the rapid and timely, beginning-at-the-bedside diagnosis, treatment and care of acute respiratory failure and curable cancer in chemically dependent patients.

Case I

History. A 23-year-old Hispanic college sophomore was admitted to the inpatient psychiatry unit with "acute anxiety." He specifically denied penicillin allergy, substance abuse and any family history of psychiatric disorder. His spleen had been removed three years previously, following a motorcycle wreck.

Physical Examination. The admitting vital signs revealed an oral temperature of 104F. During the admitting physical examination he began to cough rusty sputum.

Imaging. A chest X-ray revealed a pulmonary consolidation.

Laboratory. Sputum gram stain revealed gram-positive diplococci. Sputum culture revealed the pneumococcus sensitive to penicillin. His pneumococcal rusty pneumonia and his alleged acute anxiety resolved with the administration of penicillin and intravenous fluids. He was also provided and documented with the pneumococcal polysaccharide vaccine. He appreciated the timely diagnostics, treatment and care. Acute anxiety can have an underlying medical cause.

Critique. When our 23-year-old college sophomore was asked: "How did you come to be hospitalized on our acute inpatient psychiatric unit?" he said, "When I telephoned my student health service and I said that I was suddenly very nervous and I could not sit still, they telephoned the hospital and they put me here. The first time I was examined was after I was put in bed here." The medical physical examination of our patient led to his sputum gram stain and chest X-ray, which led directly to his diagnosis of pneumonia.

Case II

History. A 42-year-old African American male was seen in ambulatory aftercare a month following a drinking binge stating, "Doctor, this will only take a moment. I only want my Antabuse [disulfiram] re-started, one-half a pill every Friday morning. I know that is all I need, because I only drink on weekends. Oh, and Doctor, I would like my dentures adjusted." The patient took no other medications regularly. There was no evidence of liver, cardiovascular, pulmonary, renal or diabetes disorders. The patient presented with his significant other who pledged to now watch and thank him for taking his weekly medication, and the patient pledged to thank his significant other for watching him take it. Further, the patient and his significant other pledged to begin, for the first time, 12-step work with sponsorship.

Physical Examination. This robust, muscular man was seen to have a soft tissue lesion on his lower lip.

Patient Education. When I recommended surgical excision of his lower lip lesion, he said he was not worried about it because it did not hurt or bleed. "I just want my dentures adjusted," he repeated, "and I want to re-start my weekly Antabuse. Now can we get that done, Doctor?" I just sat quietly; not speaking, not moving, not writing, not typing, just maintaining eye contact with him and letting him and his significant other feel my concern for him as a person, as well as a patient. After a moment the patient said, "OK, Doctor, I will have it cut off of my lip, but also make sure that my dentures are adjusted and my weekly Antabuse is re-started!"

Consultation. The patient was provided with timely and definitive dental oral surgical treatment and care. Disulfiram was provided; 125 mg taken by mouth once a week every Friday morning, per the specific request of the patient and his significant other. The histopathologic report of his soft tissue lip lesion was squamous cell carcinoma, completely excised. The patient said he appreciated the adjustment of his dentures and the excision of the cancer on his lower lip. He thanked me for providing his "weekly Antabuse as one of his Tools of Recovery" (Grossman, 2001). Twelve-step work with sponsorship was recommended (and documented) for him and for his significant other to develop and use their Tools of Recovery.

Critique. Our chemically dependent patients' needs may differ from their wants. The painless feature of his lip tumor led me directly to the diagnosis!

Case III

History. A 49-year-old Native American woman was admitted to the inpatient psychiatry service to sleep off a drinking binge. On her second hospital day she complained of "belly discomfort."

Physical Examination. Her temperature was normal.

Laboratory. Her urinalysis was well within the reference ranges of our laboratory. Specifically, there were no red blood cells in the microscopic examination of her urinary sediment.

Ultrasound. Her belly ultrasound revealed a right kidney mass with no gallstones visualized.

Surgical operation and (tumor board) pathology. Her right kidney mass was surgically removed. Histopathologic examination revealed a carcinoma of her kidney, but there was no cancer invasion of her renal vein or renal capsule. The chief of surgery commented, "The kidney cancers that we cure are the ones which we find incidentally." The patient expressed her thanks for our timely diagnostics, treatment and care. Twelve-step work with sponsorship was recommended (and documented) to help her to develop and use her Tools of Recovery. Curable cancer may be found in our chemically dependent patients.

Critique. The diagnosis of kidney cancer in this woman was an incidental finding. The kidney is normally difficult to assess on a medical physical examination. The absence of fever and of red blood cells in the patient's urine made the diagnosis of kidney malignancy more challenging. From this woman we relearn our limitations.

Discussion and Conclusions

This review would appear to document that attention by addiction treatment team members to the baseline and periodic vital signs, including but not limited to computerized documentation of the pulse rate, blood pressure and temperature respiratory rate as well as attention to the baseline and periodic bedside physical diagnosis (Modai and Rabinowitz, 1993), including but not limited to the level of consciousness and the general appearance of the patient, ensures a high probability of definitive and timely identification and treatment of the medical and/or surgical issues found on an inpatient psychiatry service.

While it is generally appreciated that our chemically dependent patients may well be afflicted with chronic disorders, my focus in this paper is to address the issue of the diagnosis and treatment of the acute and potentially life-threatening disorders of these patients. Coordination of care may be best achieved by recognizing that:

• Chemically dependent patients may well be medically as well as psychiatrically ill.

• As with any patient admitted and hospitalized on a medical and/or surgical unit, chemically dependent patients require a reasonably complete history and physical examination.

• Chemically dependent patients must be viewed as whole patients rather than simply labeled with tunnel vision as "just an addict" or "just a drunk."

• Last, and perhaps most important, counterphobia, when and if it occurs in health care providers, needs to be confronted and addressed.

Decades ago, "alcoholics" and "addicts" were provided with just halfway houses. Then, for a period of several decades, we provided residential inpatient chemical dependency units. Now, with the closing of our residential inpatient units and our return to just halfway houses (or in some instances, three-quarter travel-under-escort housing), we may have come full circle. This is just the time to approach our chemically dependent patients with renewed enthusiasm and intensity of purpose, to focus our history and physical examinations in order to identify both acute conditions and chronic conditions.

Our addiction treatment team meetings provide us with an opportunity to share our provider learning experiences with each other. Lessons we have learned include:

• The value of our search for underlying medical issues.

• The value of consultation with our fellow surgical providers.

• The value of consultation with our fellow critical care providers.

• The value of our ongoing search for curable malignancy.

• The value of our endeavors to refocus our efforts on the medical needs of our patients.

The two core principles in the diagnosis, treatment and care of our chemically dependent patients would appear to be logic and humility. Decades ago, as an undergraduate at Johns Hopkins University, I learned to avoid the fallacy of "Post hoc, ergo propter hoc." Logic empowers me to search for any and all underlying, treatable, curable causes. Appropriate humility leads me to the realization that curable malignancy may well be discovered incidentally and that it may not be the initial primary focus of the patient, and my humility mandates my sitting down personally with every patient from whom and for whom we need to obtain written, witnessed operative procedure consent. After any surgical procedures my patients are encouraged to follow-up with me. This includes calling and writing to inform me of how they are doing. My patients know that I am concerned about them as people as well as patients. My patients and I also know that the best laboratory test is the second office visit. I recall the words of a dean spoken to the graduating class of a respected medical school in the South, "All you need to know after medical school is to remember to say, 'I don't know how to do thisPlease help me!'"

With the realization that our chemically dependent patients deserve the very best of our knowledge and experience, we can make all due reasonable efforts and attempts to "keep the medicine in psychiatry."

References:

• References 1. Glassman AH, Shapiro PA (1998), Depression and the course of coronary artery disease. Am J Psychiatry 155(1):4-11.
  2. Grossman J (2001), Disulfiram-one tool of recovery. Psychiatric Times 18(8):1, 6-12.
  3. Modai I, Rabinowitz J (1993), Why and how to establish a computerized system for psychiatric case records. Hosp Community Psychiatry 44(11):1091-1095 [see comment].
  4. Musselman DL, Evans DL, Nemeroff CB (1998), The relationship of depression to cardiovascular disease: epidemiology, biology, and treatment. Arch Gen Psychiatry 55(7):580-592.