case files

OK, gotta revive the blog.

I have two plans for this. The first is to start writing about my patients, who always turn out to be interesting people. This will also help me remember the ones worth remembering, as I think it will be one of those things that will fade with time even though when you're working with the person you swear you'll never be able to forget them or that experience.

The other idea is to start chronicling what my neighbors put on the curb on garbage night, because it is always amazing. This week it was an entire couch, with throw pillows. Often it is much more bizarre, like a single sneaker that was clearly purchased and worn in the 1970s. This section will include photos.


So I have this one 76 year old white female who came into the hospital with confusion. She had been babbling nonsense for an entire 24 hours before her family brought her in. In the ED they found she had a sodium of 118, normal being 136-144ish. This can make you confused. About two weeks beforehand she had been down to Hopkins to have surgery to repair a Zenker's diverticulum, an outpouching from your esophagus; the thought was that she hadn't been eating quite right before and since then and that's why her sodium was low.

We started trying to replete (replace) her sodium and it was slow-going. She stayed loopy in the hospital, frquently perseverating, meaning she would get stuck on one thing like wanting to take a shower and talk about it constantly, or more bizarre, just get stuck on one sentence that she would repeat over and over and over, changing maybe one word in the sentence every minute or so so that the sentence slowly morphed and made less and less sense. She also decided to repeat "You know I hate red hair" for a half hour one morning.

The lab work was confusing at first, but evertually led the kidney doctor to think this is SIADH, a syndrome where you secrete too much of a hormone that makes you retain water, thus dilluting your sodium. Surgery in the center of your chest, your mediastinum, (such as a Zenker's diverticulum repair two weeks earlier) can kick off SIADH so we thought it made sense. Nonetheless, the kidney doc wanted a CT of the lady's chest. We thought it was kind of pointless, but we got it... and there in her left lung was a big old tumor.

Meanwhile, the patient stayed loopy. However, it wasn't the typical just 'obtunded' mental status that you would expect with low sodium. Her behavior had changed from perseverating into what can only be called hypersexuality. The nurses often had to close the door to her room to give her privacy. We got stuck in a kind of catch-22: we needed more tests to work up this lung tumor as well as to work up this behavior but we were having trouble getting the tests because of the behavior! I'll just say it straight out -- my patient was kicked out the MRI suite for masturbating while INSIDE the MRI machine getting scanned. "Image artifact due to patient movement."

We discovered the combination of Zyprexa and Ativan seems to calm things down enough to get through a test, so we got the bronchoscopy today to hopefully pin down the lung mass. The sodium is being stubborn; only 3% normal saline moves it at all. We got her into the normal range for one day last weekend and her mental status did improve, which is our one shred of evidence that this behavior is sodium-related, since this isn't a textbook case at all. We had some improvement both in sodium and mental status today again finally. But, to my frustration, Renal stopped the 3% again today and put her on salt pills (something she could go home on if it works) but I expect her sodium to start sinking again tomorrow. Then we will go back to living in an X-rated movie. (I will spare you the words that come of our this woman's mouth!)

Tomorrow is my last day treating her, and I feel kind of bad saying I'm glad about this! Besides the red hair comments, she makes it very clear that she doesn't like me. I don't take it personally because usually she's too out of it to take responsibility for what she says, but it is kind of hard to walk into that every morning.

The end.