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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 13 of 13. This is the beginning of the thread.
Posted by mtdewcmu on May 7, 2011, at 14:12:38
http://www.nytimes.com/2011/05/08/magazine/mag-08Diagnosis-t.html?hpw
This is an interesting piece in the NY Times Magazine where you get to play doctor and try to guess this patient's mystery disease. In her case, the doctors, too, missed the diagnosis until about 6 months had gone by with a lot of suffering and frustration. I'm going to ruin the surprise because I want to make a point. The lady had Cushing Syndrome, caused by a pituitary tumor. The disappointing part is that the psychiatrist utterly failed to contribute to the diagnosis. He or she was called in because the lady was having symptoms superficially resembling some kind of bipolar disorder. However, the symptoms began in her mid-seventies, and were accompanied by a bunch of obviously non-psychiatric symptoms. The diagnosis of bipolar was made. You would like to think that a psychiatrist, being an MD, would be able to differentially diagnose psych versus organic diseases. At least for endocrine diseases, because the endocrine system is so closely related to the nervous system. But I guess, in a lot of cases, psychiatrists put their diagnostic skills out to pasture.
Posted by Phillipa on May 7, 2011, at 19:36:13
In reply to Case study of endocrine disorder mimicking bipolar, posted by mtdewcmu on May 7, 2011, at 14:12:38
Since my Mother had Addison's Disease the opposite of Cushings I've read up on both as once they thought I had Cushings do to urinating so much. I do know cortisone causes horrible psychiatic problems and hers was high as stated. And if she had thyroid disease why wasn't another autoimmune disease suspected? And for first time symptoms of a psychosis to pop up I feel a little old for bipolar. Yes stress probably or could have caused the raised cortisol. Many older patients also experience dementia. Endo could have done testing. Or the hospital. So much is mised in older people sad but true. Thanks for the article. Phillipa
Posted by mtdewcmu on May 7, 2011, at 20:44:41
In reply to Re: Case study of endocrine disorder mimicking bipolar » mtdewcmu, posted by Phillipa on May 7, 2011, at 19:36:13
> Since my Mother had Addison's Disease the opposite of Cushings I've read up on both as once they thought I had Cushings do to urinating so much. I do know cortisone causes horrible psychiatic problems and hers was high as stated. And if she had thyroid disease why wasn't another autoimmune disease suspected?
They believe it was a pituitary tumor, which is not associated with autoimmunity. Although, they never saw the tumor; they think it's too small to be seen.
I tried to think whether a pituitary tumor could have caused the thyroid issue as well, but I don't think it would cause one to go low and one to go high.
> And for first time symptoms of a psychosis to pop up I feel a little old for bipolar. Yes stress probably or could have caused the raised cortisol. Many older patients also experience dementia. Endo could have done testing. Or the hospital. So much is mised in older people sad but true. Thanks for the article. Phillipa
She probably would have stood a better chance by seeing a specialist in geriatrics (assuming she didn't), but there are not many of them.
Posted by Phillipa on May 7, 2011, at 21:40:03
In reply to Re: Case study of endocrine disorder mimicking bipolar » Phillipa, posted by mtdewcmu on May 7, 2011, at 20:44:41
Seriously I have a small 3cc pituitary on MRI not large enough to be considered a macro as mine is micro. A neighbor has one that measures 8 and if reaches 9 was told it would have to be removed. To my knowledge google pituitary tumors and lot of stuff on lactation with one. Something doesn't fit to me in this article. But I'm not a doc. Phillipa
Posted by mtdewcmu on May 7, 2011, at 22:05:07
In reply to Re: Case study of endocrine disorder mimicking bipolar » mtdewcmu, posted by Phillipa on May 7, 2011, at 21:40:03
> Seriously I have a small 3cc pituitary on MRI not large enough to be considered a macro as mine is micro. A neighbor has one that measures 8 and if reaches 9 was told it would have to be removed. To my knowledge google pituitary tumors and lot of stuff on lactation with one. Something doesn't fit to me in this article. But I'm not a doc. Phillipa
The thing that is suspect is that they diagnosed a tumor, but they didn't actually see one, so they decided that it must be really small. So how can they be 100% sure it's there?
However, her labs proved that her cortisol was elevated, and apparently that accounts for all the symptoms. I don't have a perfect recollection of Cushing syndrome's symptoms, but I don't feel like getting my text book. It must have been thoroughly combed over if they put it in the newspaper, right?
Posted by mtdewcmu on May 7, 2011, at 22:18:05
In reply to Re: Case study of endocrine disorder mimicking bipolar » mtdewcmu, posted by Phillipa on May 7, 2011, at 21:40:03
> Seriously I have a small 3cc pituitary on MRI not large enough to be considered a macro as mine is micro. A neighbor has one that measures 8 and if reaches 9 was told it would have to be removed. To my knowledge google pituitary tumors and lot of stuff on lactation with one. Something doesn't fit to me in this article. But I'm not a doc. Phillipa
Wikipedia says that tumors elsewhere in the body can secrete ACTH and cause Cushing syndrome, such as in small-cell lung cancer. I would not be too reassured if the doctors said it must be on the pituitary, but too small to see, and not to worry, right? She is at the age where cancer is a distinct possibility. It would really be amazing if they put the case study in the newspaper and still managed to miss the major diagnosis. But I did too much second-guessing of the docs when I worked at the hospital, and probably became a nuisance. So we should not think about it.
Posted by Phillipa on May 7, 2011, at 23:25:32
In reply to Re: Case study of endocrine disorder mimicking bipolar » Phillipa, posted by mtdewcmu on May 7, 2011, at 22:18:05
I think it's important to second guess the docs same here when hospital. But lots of times the docs had a ahhhh moment when we suggested something and they hadn't thought of it. So Wiki has an article on Cushings and did you check wiki for pituitary gland microadenomas where it shows lactation. If not for us a lot of sicker people. Yes that would be something if the paper were wrong!!!! Phillipa
Posted by bleauberry on May 8, 2011, at 5:10:57
In reply to Case study of endocrine disorder mimicking bipolar, posted by mtdewcmu on May 7, 2011, at 14:12:38
Based on my own accidental discoveries in my own drug/herb journeys, I found out there is a powerful connection between endocrine system and mood. Immune system...same thing. The most incapacitating depressions can be improved or cured with substances that are not even psychoactive.
I've had over 12 psychiatrists and not one of them had any diagnostic skills. A couple times they checked basic thyroid, but not the indepth detailed tests, B12, and magnesiium. Tested for Lyme twice or 3 times. All useless and unreliable. They totally missed the hypoadrenalism and it probably never even showed up on their radar screen of ideas.
It is my opinion based on a whole bunch of stuff that many, if not most, psych patients are dealing with something that can be successfully treated....but the singular pscychiatric prescription approach misses almost all the possible contenders. In other words, I truly believe improvement is possible....but greatly limited when our weapons are only psych meds.
Unfortunately we don't have the right tests in today's technology. For the tests we do have, there is a great deal of room to make error in reading the results. For example, someone who shows a fairly normal thyroid level can in fact be seriously hypothyroid. It's all in how the test is interpreted. Many clinicians make the mistake of judging test results in a vacuum, discounting the actual clinical picture. The clinical picture is what should guide treatment. In the example you gave, which is all too common, the clinical picture was ignored.
In a perfect world it would be nice if doctors would rule out organic diseases or identifiable problems. I never saw them do that with me. Even if they had, the only true way to rule something in or out is to try treating it as if it existed to see what happens. That provides the information and clues to rule something in or out with a strong degree of certainty. Even though I had all the presentations of Lyme, as soon as the test came back negative, guess what, they ruled out Lyme....bad mistake that cost me almost 15 years, psych ward stays, and multiple drug failures. A simple 2 week trial of Doxycylcine would have been a much more accurate diagnostic tool than the test. I mean, come on, I did get bit by a tick, ok? Oh, but that only happens to other people. Yeah right.
> http://www.nytimes.com/2011/05/08/magazine/mag-08Diagnosis-t.html?hpw
>
> This is an interesting piece in the NY Times Magazine where you get to play doctor and try to guess this patient's mystery disease. In her case, the doctors, too, missed the diagnosis until about 6 months had gone by with a lot of suffering and frustration. I'm going to ruin the surprise because I want to make a point. The lady had Cushing Syndrome, caused by a pituitary tumor. The disappointing part is that the psychiatrist utterly failed to contribute to the diagnosis. He or she was called in because the lady was having symptoms superficially resembling some kind of bipolar disorder. However, the symptoms began in her mid-seventies, and were accompanied by a bunch of obviously non-psychiatric symptoms. The diagnosis of bipolar was made. You would like to think that a psychiatrist, being an MD, would be able to differentially diagnose psych versus organic diseases. At least for endocrine diseases, because the endocrine system is so closely related to the nervous system. But I guess, in a lot of cases, psychiatrists put their diagnostic skills out to pasture.
Posted by mtdewcmu on May 8, 2011, at 17:16:31
In reply to Re: Case study of endocrine disorder mimicking bipolar » mtdewcmu, posted by Phillipa on May 7, 2011, at 23:25:32
> I think it's important to second guess the docs same here when hospital. But lots of times the docs had a ahhhh moment when we suggested something and they hadn't thought of it.
I'm pretty sure they didn't want suggestions from me, because I had no status. The charge nurse they would take seriously. But, my mind was always working. It would have been better if my mind had been more focused on doing my own job.
Once, I had a woman patient who had this recent history of bizarre behavior, and she a body that looked like the description of Cushing syndrome. She was in some state of delirium or psychosis in the hospital. She was being treated for some kind of accident or something -- something surgical. So medical stuff was not the priority. I managed to convince one of the RNs that her cortisol should be checked. I also mentioned it to one of the interns or second year residents, and he said he'd "float the idea" with the more senior docs. But I don't think it was done. I wished I had left it alone. You have to consider who are the Indians and who are the chiefs. Can't have too many chiefs.
> So Wiki has an article on Cushings and did you check wiki for pituitary gland microadenomas where it shows lactation. If not for us a lot of sicker people. Yes that would be something if the paper were wrong!!!! Phillipa
I read about microadenomas. Looks like some produce prolactin, and others ACTH. Says it's possible that an ACTH-producing one could be invisible on MRI. But the newspaper article doesn't say they considered the ectopic kind that can be in the lungs.
Posted by mtdewcmu on May 8, 2011, at 17:54:28
In reply to Re: Case study of endocrine disorder mimicking bipolar, posted by bleauberry on May 8, 2011, at 5:10:57
> In a perfect world it would be nice if doctors would rule out organic diseases or identifiable problems. I never saw them do that with me. Even if they had, the only true way to rule something in or out is to try treating it as if it existed to see what happens. That provides the information and clues to rule something in or out with a strong degree of certainty. Even though I had all the presentations of Lyme, as soon as the test came back negative, guess what, they ruled out Lyme....bad mistake that cost me almost 15 years, psych ward stays, and multiple drug failures. A simple 2 week trial of Doxycylcine would have been a much more accurate diagnostic tool than the test. I mean, come on, I did get bit by a tick, ok? Oh, but that only happens to other people. Yeah right.
A patient who walks in to a psychiatry clinic is a different situation than a hospitalized patient with an unusual presentation and a lot going on medically. You would hope that when the patient simultaneously developed psych symptoms and became unable to walk, that the psychiatrist would consider more possibilities. In this case, a simple blood test definitively ruled in or out the disease.
Some of the stuff you are talking about is outside the mainstream of medicine, like interpreting a thyroid test as abnormal when most endocrinologists would say that it's normal. I'm pretty sure the kind of hypoadrenalism you're talking about is not the kind most experts would say needs to be treated. Lyme disease is not that common, and if you don't have the characteristic rash or any non-psychiatric symptoms, you can forgive the doctor for missing it.
The fact that this article doesn't direct any blame to the psychiatrist for missing the diagnosis shows that the expectations for psychiatry are pretty low. You can't really blame the hematologist for missing the diagnosis, since there was nothing to really learn from looking at the blood. You might expect the neurologist to have done better than to speculate on some viral mechanism and leave it at that, but I don't know as much about neurology as about psychiatry.
Posted by Phillipa on May 8, 2011, at 19:44:16
In reply to Re: Case study of endocrine disorder mimicking bipolar » bleauberry, posted by mtdewcmu on May 8, 2011, at 17:54:28
Hence admissions to the psych ward all require physical exams by a doctor some hospitals use neurologists. I worked at one that did. I'm sorry you were not taken seriously. You might have caused the patient un needed suffering. I test positive for lymes and still have six positive bands. Choice was take doxy or don't continue as took rocephin IV in hospital setting through pic line then two years of biaxin xl and still the positive bands. But they are IGG which can stay positive for years. Phillip
Posted by mtdewcmu on May 8, 2011, at 20:52:56
In reply to Re: Case study of endocrine disorder mimicking bipolar » mtdewcmu, posted by Phillipa on May 8, 2011, at 19:44:16
> Hence admissions to the psych ward all require physical exams by a doctor some hospitals use neurologists. I worked at one that did. I'm sorry you were not taken seriously. You might have caused the patient un needed suffering.
How so? By not pressing? You can only do so much when you are at the bottom of the hierarchy. Things are very regimented as it's a teaching hospital. The fellows are a little afraid of the attending, the residents of the fellows, and so on down the pecking order. I had the lowest job next to the custodian.
Posted by Phillipa on May 8, 2011, at 22:01:30
In reply to Re: Case study of endocrine disorder mimicking bipolar » Phillipa, posted by mtdewcmu on May 8, 2011, at 20:52:56
Yes I see harder for you but we did listen to our NA's and others that worked with us as they reported many important changes such as BP and I/O very important, and state of mind, how much ate. So I know at times the residents didn't have clue as to lets say how much lasix to give a patient in pulmonary edema frothing bloody sputum so they would panic and we'd tell them the dose and they would give it on medical floor. Just my experience. Phillipa
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