Case 5-2005: A Man with Depression and Shortness of Breath
http://www.100md.com
《新英格兰医药杂志》
To the Editor: In the discussion of Case 5-2005, that of a patient with invasive endocarditis possibly due to bartonella (Feb. 17 issue),1 Dr. Biddinger noted that the initial examination was normal. I beg to differ.
This patient, fired from his job only nine days before his presentation at the emergency department, had a profound physical and mental deterioration in that short time — a clear case of delirium, not depression. The fact that a patient with no previous psychiatric history was having auditory hallucinations should have pointed to this conclusion. The physical examination was grossly abnormal. A blood pressure of 97/52 mm Hg with a pulse of 102 beats per minute indicates a compensated response to volume loss, a medical rather than a psychiatric problem, as was confirmed by the initial results of laboratory tests.
Emergency physicians are all too familiar with the phenomenon of people, ill for weeks to months, whose condition deteriorates rapidly after presentation at the emergency department, often within minutes. What had changed in this patient and his family that led them to seek care only after nine days of a stunning alteration in his health and demeanor? Would one day have made a difference?
Stephen C. Acosta, M.D.
Doctors House Calls
Portland, OR 97210-1079
steve@doctorshousecalls.net
References
Case Records of the Massachusetts General Hospital (Case 5-2005). N Engl J Med 2005;352:709-716.
To the Editor: It appears to me that the extensive open heart surgery performed in this unfortunate patient was very risky and may have taken place prematurely. A better approach might have been to postpone operating and to have used intensive medical therapy until the patient's multiple problems improved. Some might have resolved, and after a few weeks, surgery might have been more successful.
Dushan J. Babich, M.D.
360 E. 72nd St.
New York, NY 10021
To the Editor: Dr. Biddinger discusses salient problematic aspects of the request for medical evaluation of patients who are to be admitted to psychiatric services ("medical clearance"). These include an impediment to further medical care, implying that the patient has no physical health problems, and the lack of quality standards for this type of evaluation.
It is important to note that similar issues also apply to the less documented, though not infrequent, request for "psychiatric clearance" — that is, psychiatric evaluation of medical patients. Patients with a history of mental illness who are stamped "psychiatrically clear" in the emergency department before admission to a medical or surgical ward are likely to receive little, if any, further psychological attention, even though psychiatric emergencies, such as suicide attempts, might evolve during their hospital stay.1 Moreover, physicians in emergency departments tend to underdiagnose psychiatric disorders2 or to dismiss information on psychiatric diagnoses in patients presenting with medical problems.3,4 These tendencies raise questions about the view of mental illness of clinicians who are not psychiatrists, and the quality of communication of psychopathologic findings from psychiatrists to other clinicians.
Raz Gross, M.D.
Columbia University Medical Center
New York, NY 10032
rg547@columbia.edu
References
Suominen K, Isometsa E, Heila H, Lonnqvist J, Henriksson M. General hospital suicides -- a psychological autopsy study in Finland. Gen Hosp Psychiatry 2002;24:412-416.
Kunen S, Niederhauser R, Smith PO, Morris JA, Marx BD. Race disparities in psychiatric rates in emergency departments. J Consult Clin Psychol 2005;73:116-126.
Mazeh D, Melamed Y, Barak Y. Treatment of referred psychiatric patients by general hospital emergency department physicians. Psychiatr Serv 2003;54:1221-1223.
Schriger DL, Gibbons PS, Langone CA, Lee S, Altshuler LL. Enabling the diagnosis of occult psychiatric illness in the emergency department: a randomized, controlled trial of the computerized, self-administered PRIME-MD diagnostic system. Ann Emerg Med 2001;37:132-140.
The authors reply: Dr. Gross appropriately raises the problem in reverse of patients who are "stamped `psychiatrically clear'" and admitted to a medical or surgical service. We would like to suggest a partial remedy for both issues. When consultants are asked to provide clearance, they should try to avoid such circumscribed labels whenever possible and instead offer a more forward-looking "plan for continuing care." Furthermore, although we recognize the time constraints faced by practitioners in a busy emergency department, we strongly recommend a face-to-face discussion between the consultant and the requesting physician to communicate pertinent issues and treatment recommendations. Such discussions frequently surmount the oversimplification inherent in labels.
We agree with Dr. Babich that performing cardiac surgery in this patient was risky, but we disagree that the surgery was performed prematurely. The patient had severe pulmonary edema caused by severe aortic insufficiency. This indicated that there had been substantial valve destruction as a consequence of the endocarditis. Furthermore, evidence of complete heart block had also developed in the patient, which lent support to the conclusion that his endocarditis was invasive. Among patients with infective endocarditis, it is well recognized by clinicians that the presence of severe valvular regurgitation associated with hemodynamic compromise, as in this case, is an indication for urgent cardiac surgery. Although it is true that there are certain circumstances in which even patients with invasive infectious endocarditis may be treated with antimicrobial therapy for some time before surgery, in this clinical setting such a strategy would have been inappropriate — and would have carried an even greater risk than did the immediate surgery.
Paul D. Biddinger, M.D.
Eric M. Isselbacher, M.D.
Massachusetts General Hospital
Boston, MA 02114
This patient, fired from his job only nine days before his presentation at the emergency department, had a profound physical and mental deterioration in that short time — a clear case of delirium, not depression. The fact that a patient with no previous psychiatric history was having auditory hallucinations should have pointed to this conclusion. The physical examination was grossly abnormal. A blood pressure of 97/52 mm Hg with a pulse of 102 beats per minute indicates a compensated response to volume loss, a medical rather than a psychiatric problem, as was confirmed by the initial results of laboratory tests.
Emergency physicians are all too familiar with the phenomenon of people, ill for weeks to months, whose condition deteriorates rapidly after presentation at the emergency department, often within minutes. What had changed in this patient and his family that led them to seek care only after nine days of a stunning alteration in his health and demeanor? Would one day have made a difference?
Stephen C. Acosta, M.D.
Doctors House Calls
Portland, OR 97210-1079
steve@doctorshousecalls.net
References
Case Records of the Massachusetts General Hospital (Case 5-2005). N Engl J Med 2005;352:709-716.
To the Editor: It appears to me that the extensive open heart surgery performed in this unfortunate patient was very risky and may have taken place prematurely. A better approach might have been to postpone operating and to have used intensive medical therapy until the patient's multiple problems improved. Some might have resolved, and after a few weeks, surgery might have been more successful.
Dushan J. Babich, M.D.
360 E. 72nd St.
New York, NY 10021
To the Editor: Dr. Biddinger discusses salient problematic aspects of the request for medical evaluation of patients who are to be admitted to psychiatric services ("medical clearance"). These include an impediment to further medical care, implying that the patient has no physical health problems, and the lack of quality standards for this type of evaluation.
It is important to note that similar issues also apply to the less documented, though not infrequent, request for "psychiatric clearance" — that is, psychiatric evaluation of medical patients. Patients with a history of mental illness who are stamped "psychiatrically clear" in the emergency department before admission to a medical or surgical ward are likely to receive little, if any, further psychological attention, even though psychiatric emergencies, such as suicide attempts, might evolve during their hospital stay.1 Moreover, physicians in emergency departments tend to underdiagnose psychiatric disorders2 or to dismiss information on psychiatric diagnoses in patients presenting with medical problems.3,4 These tendencies raise questions about the view of mental illness of clinicians who are not psychiatrists, and the quality of communication of psychopathologic findings from psychiatrists to other clinicians.
Raz Gross, M.D.
Columbia University Medical Center
New York, NY 10032
rg547@columbia.edu
References
Suominen K, Isometsa E, Heila H, Lonnqvist J, Henriksson M. General hospital suicides -- a psychological autopsy study in Finland. Gen Hosp Psychiatry 2002;24:412-416.
Kunen S, Niederhauser R, Smith PO, Morris JA, Marx BD. Race disparities in psychiatric rates in emergency departments. J Consult Clin Psychol 2005;73:116-126.
Mazeh D, Melamed Y, Barak Y. Treatment of referred psychiatric patients by general hospital emergency department physicians. Psychiatr Serv 2003;54:1221-1223.
Schriger DL, Gibbons PS, Langone CA, Lee S, Altshuler LL. Enabling the diagnosis of occult psychiatric illness in the emergency department: a randomized, controlled trial of the computerized, self-administered PRIME-MD diagnostic system. Ann Emerg Med 2001;37:132-140.
The authors reply: Dr. Gross appropriately raises the problem in reverse of patients who are "stamped `psychiatrically clear'" and admitted to a medical or surgical service. We would like to suggest a partial remedy for both issues. When consultants are asked to provide clearance, they should try to avoid such circumscribed labels whenever possible and instead offer a more forward-looking "plan for continuing care." Furthermore, although we recognize the time constraints faced by practitioners in a busy emergency department, we strongly recommend a face-to-face discussion between the consultant and the requesting physician to communicate pertinent issues and treatment recommendations. Such discussions frequently surmount the oversimplification inherent in labels.
We agree with Dr. Babich that performing cardiac surgery in this patient was risky, but we disagree that the surgery was performed prematurely. The patient had severe pulmonary edema caused by severe aortic insufficiency. This indicated that there had been substantial valve destruction as a consequence of the endocarditis. Furthermore, evidence of complete heart block had also developed in the patient, which lent support to the conclusion that his endocarditis was invasive. Among patients with infective endocarditis, it is well recognized by clinicians that the presence of severe valvular regurgitation associated with hemodynamic compromise, as in this case, is an indication for urgent cardiac surgery. Although it is true that there are certain circumstances in which even patients with invasive infectious endocarditis may be treated with antimicrobial therapy for some time before surgery, in this clinical setting such a strategy would have been inappropriate — and would have carried an even greater risk than did the immediate surgery.
Paul D. Biddinger, M.D.
Eric M. Isselbacher, M.D.
Massachusetts General Hospital
Boston, MA 02114