Thread by @medicalaxioms

I saw a lady with “rapid onset dementia” over the course of a month.
[medical story thread]

She got fired from her job because she kept forgetting things. Lost her keys and got lost. Suddenly needed help to do household chores.

When I saw her, her chief complain My was “I’m getting dementia.” She was distracted and anxious. She had already had the usual 50 medical tests for delirium and dementia and the tests you get when nobody knows what’s going on like...

B12, TSH, CRP, cortisol, ABG, MRI, etc. etc. They were all normal.

So I figured I’d go old school and just let her talk. I just kept following up with curiosity questions whenever she seemed done with a topic: Why? Then what happened? What were you thinking? Tell me more...

Every time I do this I remember how dumb this open-ended questioning sounded as an MS1 at @CWRUSOM in 1992 when they videoed us talking to practice patients.

Every time, I think “this is silly but I know it’s supposed to work.”

We talked for a long time. A few times she would start to say something and then say, “Oh I shouldn’t tell you that” or “this doesn’t really matter.” I gave my usual answers “I can take it,” “this so a safe place,” “you can tell me–you’ll never see me again.”

The conversation started like one of those Oliver Sacks stories where a little piece of the brain falls off and you start brushing your teeth with a Cadillac.

I had her do those neuro mental gymnastics tests. I even had her remember 3 objects: ball flag and tree.

After awhile it turned from a clinical story of neurological dysfunction into a story about feelings. There was an abusive alcoholic ex husband. Relationships with kids severed. Scary events with lots of vivid details.

Then things changed. There was all this crying. Like rivers of crying. Each time it settled down I would ask another question and she would find another painful story. A vivid description of an argument or fight or something terrible. Really heartbreaking.

I really lost track of time. I didn’t see any other way to get to where I wanted to go than by doing what I was doing. I slipped in a typical prayer: “Please gods protect me for the next half hour from another admission. I think I am doing something worthwhile.”

After a lot of Kleenexes and emotions, she got quiet. I circled on back to one of my favorite questions: “What exactly happened right when all these symptoms started?”

Turns out she had made an offer on a new place to live.

All her stories had been about loss of control. Insecurity. Being manipulated and dominated by others. Fear of mean people and inability to leave because of financial and other pressures.

At the end of our ?45 minute conversation, I asked her the 3 words I had her remember at the very beginning. She said “ball, flag and tree.” I called a psychiatry consult very sure they were going to come back with a neurological diagnosis I hadn’t heard of.

In fact they came to the same conclusion I did: she had PTSD and severe depression with psychotic features. It was a big relief. They said I was on the right track. 🤓

I was told later she got a lot better with the right treatment.

We make both errors in medicine: we
1) call people “crazy” when they are organically ill and
2) do endless tests to find a anatomical, hormonal, infectious or malignant problem when the problem is somewhere in the DSM book.

I’m sure I have made both errors. In this instance, I had the luxury of time to let this person tell me what was really wrong.

I hope I am getting better and making fewer mistakes with time.