When the Patient Cannot Tell You What is Wrong.

There are no procedures in medicine for patients who not only do not know what is wrong but cannot communicate physical symptoms because they are too unwell. This category of patients is very broad and includes neurological patients, cardiac patients, organ failure patients, neuropsychiatric patients-ambulatory or not.

I have been watching the Netflix series on difficult diagnosis, produced with the help of the New York Times and thus far, most of the patients with unexplained symptoms are lucid, very verbal and can explain in great detail what is ailing them. It is difficult enough, sometimes to come up with the correct diagnosis, when the patient can describe their symptoms; imagine the difficulties when they cannot.

To his student doctors, Sir William Osler said; “Just listen to your patient, he is telling you the diagnosis.” By emphasising the centrality of history-taking and the examination of patients, Osler compressed the course of undergraduate and postgraduate development. Osler compressed the course of undergraduate and postgraduate development. Physicians would no longer embark on a haphazard journey of discovery but would acquire clinical method at the beginning of their vocation. William Osler: A Life in Medicine BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7268.1087/a (Published 28 October 2000); s: BMJ 2000;321:1087

Osler emphasized history taking AND examination of patients; by listening, he meant both.

Ventilatory failure [with or without normal lung function] can be very tricky. Any organ failure can be tricky. This is because organ failure can be a gradual process, one that just creeps along and does not appear on any test results, except when well advanced.

The connection between organ failure and brain function is obvious to me, because of the brains immense need for nutrients and circulation of blood. The connection between ventilatory sufficiency and proper function of the mind is even tighter because respiratory rate and lung function are indirect indicators of the partial pressure of carbon dioxide or PCO2. PCO2 is part of acid base balance of the blood and, in part, this blanche depends on being able to physically move air in and out of the body using the windpipe, neck and torso apparatus [airway, ganglions, sensors, nerve fibres, rig cage, spine, torso muscles].

aIf you cannot move air in and out of your body sufficiently, then -even if your lungs are fine- you will have difficulty maintaining your ability to think, remember, speak or even move voluntarily.

This is what happened to Paula, during a minor physical illness in the midst of normal hormonal change [menopause].

Earlier blogposts describes how sick she got, feeling a dyspnea she did not recognize and could not describe [now remembered as a never-ending anguish, distress and fear].

Only measurements of her vital signs would have made the diagnosis; no one could take a valid history because she was too mentally impaired to give a coherent or accurate one. Truth was, she had no idea what was wrong.

No one measures vital signs first thing anymore. If someone had, a lot of wasted time and incorrect treatments would have been avoided.

A history would have yielded little useful information because all Paula could say [in 2-3 word stilted, hesitant soundbites] was that she woke up like this and felt awful and did not know why. When pressed for details she appeared confused and/or depressed.

If Paula’s doctor had measured her vital signs at rest, in a sitting or lying down position, before offering a diagnosis they would’ve gotten the following results.

RR = 3 breaths per minute [depressed respirations ] with active exhaling [using abdominal muscles to squeeze out air the exhaling, indicating her difficulty moving air in and out].

BP= Very high

HR = high Heart sounds = occasional palpitations or arrhythmia’s, murmur,

Body temperature = mild hypothermic range [depressed body temperature].

Circulation = pale cold hands and feet and lips [lips a little blue].

Mental status = depressed, cannot remember her own address or postal code

Work status = is a university educated college teacher.

What would your diagnosis be?

Dr Kraepelin, in the early 20th century found thousands of patients with the same vital signs, suffering from attacks of major depressive insanity, which he thought was due to the same ventilatory defect that Paula displays [depressing respiratory rate]. Dr Kraepelin’s patients, when ill and depressed, also had too high blood pressure, abnormal heart sounds, fast heart rates and lowered body temperature and memory difficulties.

In Kraepelin’s day, I do not think spirometry existed.

Today, in the 21st century Paula’s doctor would have been able to get her tidal volume to see what her lung function was;

Tidal Volume = 750-850ml which is very good, better than normal- no lung issues.

This means that Paula can defend her blood gas exchange despite her low respiratory rate. Her respiratory controllers [the brain] are working fine.

The doctor we saw [years after, during a relapse] was very worried and was stumped and had never seen anything like this and did not know what to do [except to look and act panicked and do nothing].

No doctor in the current century had ever seen this because no doctor measures vital signs, except for blood pressure. The especially do not measure respiratory rate at rest.

When Paula got better, the doctor had managed to think about sending her for a few tests and we found out that her HCO3 and her O2 [pulse oximetry] were normal. When she got better, her blood pressure, heart rate and heart sounds, and body temperature returned to normal. Her respiratory rate remained depressed at 3 breaths per minute. When she got better her memory for her own address and postal code returned.

So what do you think happened to Paula? What is her diagnosis? When ill? When better?



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