Jewell

⇒ In July 1982, I began my psychiatry residency on the University of Oklahoma’s inpatient psychiatry unit. Jewell-my first patient-had been on the unit over a month. Despite maximum doses of an antidepressant and an antipsychotic, she remained floridly psychotic, hostile, and angry. The addition of benzodiazepines had not calmed her. Her initial diagnosis had been “depression with psychotic features; rule out dementia.”

Jewell-a 59-year-old, widowed Caucasian with no history of medical or psychiatric problems-had become depressed some months earlier. Unsuccessful treatment led to a transfer to a nursing home in north Texas. Her home of record was 5 miles away, where she had lived with her son.

Admitting history, physical exam, x-ray, EKG, and laboratory findings were unremarkable, except for moderate obesity. Medicine and neurology consultations were obtained. Dementia was suspected, although not diagnosable at the time.

Two days before our first meeting, Jewell became agitated and began kicking a large trashcan, which resulted in a fracture of her right leg and the need for a cast. After this incident, she became less physically aggressive, but her verbal hostility was unabated. She paid no attention to her appearance, and remained in a hospital gown and dressing robe. Most patients wore street garb by the fifth day on this unit.

I had seen Jewell from a distance during the unit’s annual outing. Even in that group she was odd-not just because she was dressed in a hospital gown and robe. There was something about the way she walked.

She was barely civil to me. She said I reminded her of her son, Billy. He was described in the nursing notes as unfriendly and pompous. I asked her about her anger. She told me she was mad at Clint.

“Clint?” I said in my best Rogerian form.

“You’re about as dumb as Billy, too,” she said. “Clint is my one true love.”

“I don’t see his name on any of the visit sheets,” I said, looking through her chart.

“Of course not,” she said, shaking her disheveled hair and patting the wall. “He’s in the room behind mine. We talk every night just after those Nazis put out the lights. I sit in that chair and lean against the wall, so they don’t hassle me.”

She sat on her bed. I sat on the chair by the foot of her bed. Bed and chair stood against the wall she patted. The other side of this wall faced a parking lot. There was no room.

“So, how long have you and Clint been involved?”

“In love,” she corrected, not pleasantly.

“In love . . .were you with him in Texas? You remember you transferred here from the nursing home?”

“Of course I remember, I’m suposed to be crazy, not retarded. Clint and I have been together about a year. In fact, last week was our anniversary. Clint, like any man, forgot the anniversary. That’s why I was angry.” She sighed, looking at her leg, “No way we can elope now.”

“Yes. . . the notes mention you’re not socializing with the other patients. Why is that?”

“Clint is all I need. Has been ever since we met,” she sighed and her eyes glanced at the wall. As we talked, she became less hostile.

I got more information about Clint. He was a long-haul trucker, originally from Abilene. He was also the source of her fight with her son and why her son had not visited in over a month. The son called her crazy, and she had thrown him out.

I found my neurology class notes and read up on B₁₂ deficiencies. The lecture, ironically, was given by the same person who had provided Jewell’s neurology consult. I was convinced Jewell had presented with megaloblastic madness. More than that, I thought she had pernicious anemia.

I sent a blood sample for a B₁₂ and folate assay. I also ordered a repeat CBC. The CBC was back first and showed her red blood cells were now minimally megaloblastic-100.3 µm³ (99 being the upper limit of normal). Two days later the assay came back: normal B₁₂ is greater than 200 ng. Jewell’s sample was 37. I repeated the lab. The next report came back at “<50 ng.” I wrote orders for a hematology consult citing pernicious anemia as the reason.

The hematology consult was done by the chief resident in medicine. He had the gentlest bedside manner I had ever seen. He even charmed Jewell. He explained to her they would need a “bone marrow aspirate” but that the procedure could be painful. He explained it plainly. Amazingly, Jewell agreed. She endured the procedure and the retinue of students who accompanied the chief resident on his visit.

A few days later, I found the chief resident writing in Jewell’s chart. He looked up and smiled.

“The chief hematologist, and head of the lab says this is the earliest pernicious anemia he’s ever seen . . . and I read your notes. You saw megaloblastic madness that even the neurologist missed. Amazing ‘Swami’ work, Luc!” “Swami” was used to describe someone pulling an accurate diagnosis seemingly out of thin air. He wrote detailed notes on conducting her treatment.

Medicine, neurology, and hematology services all came to examine Jewell. They congratulated the lowly psychiatrist who had made the amazing diagnosis. Who thought shrinks knew medicine?

There was talk of a follow-up bone marrow aspirate as part of an article on the case. I demurred, wanting to see how Jewell progressed.

Pernicious anemia can be treated. If treatment is started soon enough, both mental and physical symptoms can be reversed. Jewell progressed. She began to wear street clothes, had her hair done, and started to put on makeup. She became sociable and interacted pleasantly with everyone on the unit-including me.

After a month, she was ready for discharge. Arrangements were made for her to receive outpatient B12 injections on a regular basis. Her antipsychotic medications were reduced to one-tenth their former dose. Her antidepressant was now effective. Arrangements were made for her to be seen at an outpatient mental health clinic near her home.

I was full of myself as I entertained visions of a successful career in academic medicine.

Three days before her discharge, I went to Jewell’s room. She was sitting in the dark. Even in the dim light I could see she had been crying. She sobbed almost soundlessly.

“Jewell, what is it?”

When she answered, I understood that her successful treatment had a side effect.

I would not get a follow-up bone marrow aspirate: it would not help Jewell. And I lost my desire to do academic medicine.

Jewell’s answer taught me that successful diagnosis and treatment of an illness weren’t everything. They were not the most important things.

“Clint hasn’t been here for weeks,” was her response.

Disclosures:

Dr. Luc practiced psychiatry in Tulsa, OK, most recently at the VA before he retired in 2014.