cranquis:surrealmeds:The Case of the Shaky SongwriterIf I know anything about musicians, it’s that t
cranquis:surrealmeds:The Case of the Shaky SongwriterIf I know anything about musicians, it’s that they all love to drink, frequently do drugs, often have mental health issues, and almost never take care of themselves as they should. When Tim (age 57, not his real name, not a real case, put together from several cases for your learning and enjoyment) came in complaining about his new, essential tremor, I asked him about how it was affecting his life. As a songwriter, the biggest problem was in writing things out long hand and having a hard time keeping things legible. I then asked about his drinking. Tim has always hidden his drinking from me, but it’s a small town, so I’ve heard about his enjoyment of EtOH. He said he’s been trying to cut back, and has more than halved his consumption over the past month because he had noticed his tremor getting worse. A ha! I said, we have the culprit! If it doesn’t get any better, come on back to the office in 4 weeks. 4 weeks pass and Jim is back. His tremor is getting worse. I worry about alcohol induced Parkinsonism. Tim gets booked for a head CT which shows diffuse grey matter atrophy. It’s not likely enough to cause the signs and symptoms I’m seeing though. I send him to a neurologist who tries him on levo-dopa. In the meantime we do Tim’s regular blood work for his mental health meds (seroquel, lithium). Lithium comes back elevated, not by much, just a point or two. We decide to try lowering the lithium to watch the results carefully. Tim’s tremor eventually decreases and we begin to lower his levo-dopa as well, successfully. Lessons I Learned from TimPrejudice is not helpful. Knowing the gossip on the street is sometimes helpful but should not be the basis of your diagnosis. It is easy to do, to just jump to the first conclusion and go from there, but keeping an open mind is so important. Make sure your patient is comfortable coming back so you can both work on a possible cause. Always be suspicious of medications as the cause of an illness, especially when a patient is on more than 3. Docs are terrible at stopping medications. We aren’t taught it in school, and specialists are often ardent in their desire to keep patients on meds. Learning to stop meds is as important as anything else we learn. Build faith between you and your patients and make plans for close follow up and weaning off or down medications. Lots of meds need follow up. Some closer than others. Lithium in particular can be fickle. It is renally cleared which means that if your patient has acute renal failure, they may suffer from lithium toxicity. Whenever you see strange behaviour in a patient who is on lithium, do a level. It takes 3 days for us to get it back in our hospital, so don’t expect quick response back from the lab. In the meantime, if you are suspicious, it’s worth treating this patient as though they are lithium toxic. ABCs - these patients often have decreased level of consciousness. Fluid resuscitation. Be as liberal as you can be without causing CHF or more damage to the kidneys. Vomiting and diarrhea is common. Make sure electrolytes are in a safe range. Consider stopping ACEis, definitely stay away from NSAIDs, keep those kidneys as healthy as possible. Kayexelate may be helpful. If not, you might need to consider dialysis. Charcoal is useless. Don’t do that to your poor patient. Old folks have a lower eGFR, be more suspicious of toxicity with them. How a patient spends their day will determine what is they want from you. Tim was focused on his tremor because it was interfering with his writing. He didn’t notice that he was urinating all the time. We didn’t pick up on that until we were rehydrating him later. Once again, a lack of a good systems review kicked me in the ass. If I had done this at the first visit instead of gleaning onto the first diagnosis I thought of, I would have suspected lithium faster. Taking my time to do everything correctly would have saved Tim months of symptoms. The constant battle against hurry, assumption, and over-medicating. -- source link