What Do You Think the Diagnosis Is?

  • Respiratory Rate [RR] = Depressed; at 3 breaths per minute at rest lying down, uses abdominal muscles to squeeze as much air out as possible, using active exhaling. [ Medical textbooks report that an average breathing rate at rest is about 10-12 breaths per minute. Below 8 is considered to be bad. Paula’s is only 3, at rest and this is very reproducible and it does not really show unless you count her respirations very carefully at rest; [a stopwatch helps for accuracy]. ] …What does this mean?

additional information we have gleaned over time….. { O2 [pulse oximetry] is normal. No visible shortness of breath. If asked Paula reports overwhelming ongoing distress, anguish and fear. Feels ongoing [ internal] stiffness, this seems to interfere with speech production, making it harder to speak. Voice sounds quiet, and speaking takes effort- can only get 3-4 words out with great [unseen but felt] effort. [does NOT practice Yoga or take opioids].

  • Blood Pressure [BP ] = very high
  • Heart Rate [HR ] = fast
  • Heart Sounds :   Murmur, occasional palpitations and arrhythmia’s 
  • Body Temperature = lower than normal, approaching mild hypothermia
  • Circulation =  vasoconstricted ,   pale, cold hands and feet, cold, even blue lips.
  • Mental Status : abnormal, impaired: eg. Paula can not remember her own address or postal code. [we tested her-it took 5 seconds and this suggested memory difficulties and possible cognitive impairment]. She reported not understanding what she read anymore. Paula has a graduate degree and is a teacher. She is unable to work while she is impaired like this. She woke up a couple of weeks ago in this state. This is all she can report.
  • Locomotor Status : Paula is ambulatory, although her locomotor activity is also depressed, she does not move a lot, mostly she sits or paces, if very internally agitated.

This is all we have at the moment.

Any early ideas of a possible working diagnosis ?

No other tests were done on Paula.

And we got this far because of that lucky insight due to taking a basic first aid class. And , of course, because of Kraepelin’s studies.

[ Thousands of patients seen in the 1900’s by Dr Emile Kraepelin had similar patterns of vital signs and symptoms. They also were impaired in their work, or their studies or even in their ability to care for themselves. [ADL’s or Activities of Daily Living]. Their breathing rates were too low; like Paula’s. Dr Kraepelin noted that this syndrome would spontaneously lift and patients recovered their physical and mental status, with no evidence of lasting brain damage. He did not test RR during remissions. The problem with spontaneous remissions was that 1] it might take months, years or decades of suffering, for patients to spontaneously remit and 2] patients were prone to repeat attacks after periods of remission.]. However, it did prove that this syndrome was reversible unless the patient died. [back then, some did].]

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