The curious case of the confused patient....

Reflecting on the story of a patient I’d seen yesterday. A man in his mid 50s admitted under Neurology. The reason for his admission a recent episode of severe generalized muscle cramps and a sort of sudden confusional state losing the ability to recollect all the events that had happened recently. He had initially been admitted to a local hospital near his house and found to have many serious electrolyte imbalances and he was given IV corrections of the same and sent home but even when home his behavior was altered and so he was brought by his wife to my hospital and admitted under Neurology. He had had another battery of blood tests which sort of seemed grossly abnormal. He had had an MRI done which showed an old infarct meaning an old stroke and some chronic changes but nothing that explained his current neurological condition.?

The resident posted in Neurology who saw this patient was an acutely observant and extremely sincere doctor. She took a detailed history but somehow nothing she had got from him and his labs or his findings added up and she felt utterly confused. Realizing that there was something going on that she was missing but she just couldn’t understand what. So she left a note for me on my desk as to her concerns and hoping she could discuss the case personally once I’d seen the patient too.?

As I looked at all the things she had jotted down for me, I noticed her line of thinking which was really good. She had made note of a viper bite 20 years ago and one might thing what does that have to do with this and why that was a brilliant piece of history she had obtained. So well, his labs showed an evidence of low cortisol and low thyroid hormone along with a picture of low sodium and the only way to connect both these together had to be a problem in the master gland of the body, the orchestrator of many other endocrine glands of the body, the pituitary gland. Though many other pieces of the endocrine puzzle were still missing, it has been often seen in victims of viper bite who bleed post snake bite that they get a condition where the pituitary gland gets damaged from a lack of blood flow to it. And that is often associated with a lack of many hormones like cortisol, thyroid hormone and even testosterone in males and a complete interruption of normal mentrual cycles in females. A lot of which did seem to be the case with this patient. But the only thing that didn’t make sense was that if this was the case then he should be symptomatic for the past 20 years and not out of the blue right now. Unless of course he had had severe stress and that needs us to make high doses of cortisol as a survival response and the failure to do that can cause a vascular collapse and a sudden drop of blood sodium that can cause a severe generalized weakness and a severe confusional state and even coma. But that wasn’t the case here either as his sodium wasn’t that low and was pretty decent.?

His calcium levels were also precipitously low and it could very well explain his severe body pain and generalized muscle cramps of his body but it also seemed to be a chronic problem and people can walk around with calcium levels of close to 4-5 without major symptoms as their body gets used to it. His calcium was 6.6. The only way one could explain why he’d have sudden symptoms was if he was upset and was hyperventilating, meaning breathing fast and taking very shallow breaths which could cause what’s called his ionized calcium to drop that could have precipitated the symptoms but the question again came back to why this and why now as I’ve learnt from the work of Dr. Stuart Shankar, who talks about being a stress detective.?

Asked my patient and his wife who sat across me in my OPd if anything had happened in the past few days up until this that had upset him deeply in any way and they both looked at each other and said no. His wife seemed to be conflicted though but I think it felt like she wasn’t sure whether to even bring it up or not. Over the years my own own work in emotions research I’ve learnt to observe people’s body language far more intently than the words they say and I guess it’s helped me develop a sixth sense one could say that gets my antennae up for lack of a better way how to put it. Extra Sensory perception maybe? :) The stuff sci Fi movies are made of? The kind of movies Night Syamalan makes seem to allude to :) But to be honest I felt at a dead end with no further leads to go on.?

He sat before me sort of expressionless and so was his wife and on a hunch I asked him if he was the sort of person who was extremely sensitive or hurt easily because society teaches men to be not but I’ve often learnt in my own research that those are the very same men who present with many other manifestations of a deeper pain of the mind. And for a moment he looked at me like I’d hit on something. And so I probed a bit deeper and his wife was the one who said he was that way. Extremely sensitive. Asked her what did she mean. She told me that he was the man, quoting examples that if he read in the news about kids dying in Philippines he’d be so upset that he’d be beside himself. If he so much as saw a picture of hungry kids in Somalia he’d start crying his heart out. And as she said his this man’s face sort of melted and he looked at me with tears streaming down his face. Told them I understand. And I’ve also learnt that this happened in those who very born extremely emotionally sensitive but sometimes when they have had very difficult painful experiences in their childhood as only someone who’s experienced a lot of emotional pain in their younger years had such an over-expression of what one could say their empathy muscle. And why they relate deeply to another’s distress. And she said that was exactly the case for him.?

She was the one giving all the history. She said when he was small he had a very abusive alcoholic father and he’d hit and abuse him and his mother. And when he was in school he’d always be in bad company and drink a lot and then he’d come home and then he’d be hit and abused by his father for that and he’d end up spending the night out on the streets and go drink again. He had ended up falling in love with someone but she dumped him later and that caused him intense emotional pain and she remembers his mother telling her about it and how he had sort of lost it at that time and was very confused and had a hard time getting his life back together again. Told them that it has been my observation that very often kids from extremely traumatic families who don’t get the secure love they need from their parents end up falling in love early on in their lives and every often those are cases of dysfunctional cases of love and they end up in similar cycles of painful relationships that they so wanted to avoid themselves. His wife told me how that person he’d fallen in love with had gotten married to someone else after she’d dumped him and later died of cancer. He had then fallen in love again and this time she belonged to another religion and her family opposed the relationship and that ended up broken too. She was unaware about all this that had happened, before she had had an arranged marriage with him. She had come to know all this much later.?

It was only after his marriage to her that he gradually managed to cut down his drinking and slowly got his life back together again but then again they struggled with infertility for almost 7 years and it took many treatments to then have children. It was not until he’d become a father himself that he really changed and managed to be responsible. Told her all this made perfect sense to me. Asked her why I’d asked her if something had happened recently to him in any way and she said something which seemed like an afterthought but that the day this has happened he had gone to see his very close friend in the hospital who had died and somehow he found it hard to accept his death and he came back saying he could feel him around him. But it’s after that that he seemed to lose all sense. Told her sometimes severe emotional pain can cause such states that we call dissociation in medical language and can even trigger severe confusional states as the brain tries to sever the limbic feeling brain from the rational thinking brain as a protection from avoiding experiencing the deep pain one feels. And they both just looked at me. And she then went on to say how as they were on their way to being admitted to my hospital, he was talking to his wife as if he was going towards his burial service and how he could see his own tombstone and decorations on both sides and he chimed in suddenly and said he saw ‘Amazing’ written on his tombstone. Hmmm..?

Explained to them both that there were manny medical things that needed to be worked out and stuff he may need to be on medications for for hormone deficiencies but the reason why he had probably presented to the hospital recently was because of the sudden emotional pain triggering a series of brain reactions. It’s like what we’d do when we accidentally touch a hot plate. We pull back our hands to avoid more pain and the brian does this as a protective reflex but in the acute period one can feel completely lost unable to access our memory and hyperventilate which probably triggered the cramps which the IV meds helped in the short term but it was taking him longer to process the events that had just happened. Which was being able to grieve the death of his close friend and maybe being able to cry his heart out. That it was best the psychologist worked closet with him as there was so many layers to his pain that it would need a serious amount of work to help him truly heal and yet the fact that he had her and that she understood him so well I think he’d be okay eventually. Told them sometimes we see so many pieces of information but we struggle to connect the dots as we as doctors are also strapped for time to be able to take detailed histories and get to the Bottom of stuff. This was part of my own research and my own learning and I was lucky that I had some extra time on my hand and a curious resident I wanted to do justice to and why I’d explored his case at such great length. They both thanked me and I said I’d put down my thoughts and recommendations on the file and will see him with the results of his report in a day or two.?