Psych H&P

cc: "I feel really anxious."

HPI: This 25-year-old female with a history of depression and anxiety presents with a six month history of increased anxiety. She reports an increase in worrying about her career, her pets, money, and her marriage, and she cannot control these worries. She has difficulty falling asleep because of intrusive thoughts and worries, and her appetite has recently increased, with an increase in craving for sweets. She reports feeling "very tense" and fatigued. She also has some feelings of guilt, helplessness, and hopelessness with depressed mood, increased irritability, and psychomotor agitation. She feels that the increase in anxiety may be related to a difficult decision she faces in her career, but she feels that her ability to function is impaired.

PMH: Asthma, irritable bowel syndrome, GERD
PSH: No surgeries
Psych Hx: Diagnosed with depression in 2000; treated with SSRI's off and on since; she reports only occasional compliance, in part because of money
Meds: Zoloft 50 mg qd; Claritin D PRN; Prilosec OTC PRN; albuterol inhaler PRN
Allergies: NKDA

Family Hx: CAD, dyslipidemia, CVA, depression
Social Hx: Patient lives with her husband. She is a graduate student and will need to pick a career before graduation in 2008. They have no children.
Habits: Occasional alcohol, no cigarettes or drugs

ROS: Gen: + fatigue, + weight gain
HEENT: + headaches, + blurry vision (needs new glasses), + allergic rhinitis
CV: -
Lungs: -
GI: + heartburn, + abd cramps and diarrhea
MSK: + neck and back tension

PE: Gen: 25 yo WF, anxious-appearing, overweight, cooperative with exam
VS: HR 76 RR 18 BP 107/64 T 98.6
CV: RRR
Lungs: CTAB
HEENT: PERRLA, TM's clear, turbinates swollen and red, oropharynx clear
Abd: soft, NT/ND, hyperactive bowel sounds
MSK: 5/5 strength throughout, 2+ DTR's throughout
Gyn: deferred
MSE: Gen: A&O x 4
TP/TC: No AH/VH/SI/HI; goal-oriented; some derailing/thought blocking
Speech: loud, normal tone, rate, and content
Mood: anxious, irritable
Affect: anxious
Insight: good
Judgment: fair; patient did seek attention for symptoms, but isn't always compliant with medication
MMSE: 30/30

A&P: 25 yo WF with generalized anxiety disorder and depressed mood
1. Encourage patient to take currently prescribed SSRI. Consider adding buspirone for anxiety.
2. Recommend supportive therapy. Biofeedback may help this patient with prominent somatic symptoms.
3. The patient has severe anxiety regarding her decision to pursue a career in urology, and has recently begun to consider a career in psychiatry instead. Recommend the patient look at both objectively and discuss pros and cons with her family, friends, and advisors.

Surprise!

What does a health care crisis look like?

Just read this article from the front page of yesterday's USA Today to find out. Photos of the waiting lines at the Ben Taub clinics are shown; one patient spent 8.5 hours for an orthopedics appointment. They also mention that Harris County has one of the highest rates of uninsured people in the country (30%), so these HCHD systems are totally overloaded.

Amazing that an institution not too far away (maybe only a state or two) made a national newspaper.

Different Continents

For a reason I can't quite figure out, different areas of my hospital have marked differences in their quality of care. The ICU's seem to be well-staffed, with a team of doctors, nurses, physical therapists, respiratory techs, case managers and social workers who collaborate to achieve fantastic results for their patients. The pediatric floors tend to have a well-working team system as well. The pedi nurses tend to be great; I've met a few who were brusque, but their interactions with the kids were good. The stroke team was an actual TEAM; we'd meet with the nurses and case managers to plan the stay and outpatient care every day, so that everyone knew patient C would be going to LTAC after PT cleared his swallow study, etc.

However, other parts of the hospital are not so nice. One floor had nurses that complained every time a patient was admitted to their care. Loudly. In the public nurses' station, where anyone could hear. Same floor, we had a patient who was supposed to be anticoagulated before discharge. His INR peaked at around 2, then began to fall again. We couldn't figure out what was going on. After three days, the resident figured out that nursing wasn't giving the anticoagulant. It was ordered, it had been given previously, but for some reason it slipped through the cracks and this guy's discharge was delayed for a week because of it. The medical and surgical floors are infamously known for "forgetting" patients--whether true or not, care does not get coordinated into large multidisciplinary teams here.

I've come to a couple of conclusions, and I feel that architecture is responsible for many of these differences.

The ICU's are generally isolated large rooms, with multiple patients inside. Nursing stations are large and arranged with clear visibility of the beds; even in an ICU with patients in separated rooms, nurses can see into the rooms--the doors are glass and often open. Patients are always visible to the nurses. The stroke unit is a separate room with only about 10 beds. The pediatric floors are arranged in "pods", with six or so rooms per small nursing station. Again, each room is visible to the nurses at all times, and the doors are often open. Each nursing station is in charge of a small number of beds.

The medical and surgical floors are in an older building than the pedi floors. A long rectangle has a nursing station at either end, two per floor. Patient rooms open off on all sides of the rectangle; some are as far as 50 feet from a nursing station and around a blind corner. The doors are usually closed. Each nursing station is in charge of about 30 patients. The design is less conducive to constant monitoring, and walls patients off in private rooms where they often feel forgotten.

It seems to me that the issue is twofold. One, each nursing station should be in view of all the patients it covers. Second, each nursing station should be in charge of fewer patients. The issue doesn't seem to be a nursing shortage, but rather a shortage of patient visibility. For whatever reason, units with better-coordinated care are isolated or have patient "pods" for more focused care.

Future Architects of America, pay attention: when designing hospitals, function follows form.

Crazy Doctors

The attending I worked with this afternoon had on an outfit so crazy that I couldn't find anything comparable on Google Images. She was wearing a pair of cream colored capri pants with a graded pattern of black fish, with the most fish around the leg bottoms tapering off higher up; a wine-colored shirt; a set of Celtic cross earrings and necklace in silver and turquoise; and a pair of black Dansko clogs without socks, which go so well with capris. What really made the outfit, though, was her jacket. It was made of crinkled satin-y material (I think it's called crepe), fitted close to the body, with an oddly floppy collar. The print varied wildly: the right front panel was a loud orange with an Asian dragon-type pattern in turquoise with maroon sequins; the left front panel was dark green with a small, busy and meaningless gold pattern; around the back of the jacket, the majority was the orange pattern again, with a small bit under the right arm in the green for contrast; and around the left arm, the green pattern gave way to a solid maroon running directly up the underside of her arm into her armpit.

The whole effect was so strikingly weird that I kept staring at it all afternoon. It was like watching a walking Rorschach test all day. I just kept thinking, this is like the description of schizotypal personality disorder that I Just read about. It's a good thing that the room we watched family therapy in (through one-way mirrors) was pitch black, so I couldn't stare at it too hard while we were in there.

Mister TB Man

I just feel like I have to add my two cents' worth to this story. Reading quotes from this guy saying he's sorry he endangered people, he didn't know is really making me angry.

The Facts (As I Understand Them):

A lawyer from Atlanta was scheduled to get married in Greece. Shortly before boarding his plane, he was told he had drug-resistant tuberculosis. Apparently, he had been treated for TB before, and often travels to TB-endemic countries. His father apparently recorded a health official as saying that they preferred he not fly to cover themselves, not because he was a danger to anyone, as his risk of contagiousness was low. Since officials told him "we prefer you not fly", but never directly forbade him to fly, he decided that he would fly to Europe with his fiancee to get married.

After he left his apartment, CDC officials tried to contact him to say his diagnosis had changed from drug-resistant TB to extensively drug resistant TB, or XDR-TB. Apparently only 49 cases have been reported in the United States until this time. Thus far, the best treatments achieve only 20-30% cure rates for XDR-TB. It was too late--he was already on his way to Europe.

Once in Europe, where Greek officials are denying he ever filed marriage paperwork, CDC officials were able to reach the man and inform him of his condition. CDC claims they told him to stay put, as they would try to figure out a way to bring him back to the US safely. He claims he was told to turn himself in to Italian authorities, where he feared he'd never be released and would die. So, he and his new wife(?) hop the first plane from Prague to Canada, figuring they'd evade US Customs. Indeed, he drove safely across the border into New York, despite his passport being flagged. Fortunately, once in New York, he turned himself in, and has since been flown to Georgia and then Denver, where he can receive treatment for his TB.

My Interpretation of the Facts:

I'll come out and say it--I think this guy's an idiot.

Perhaps they never quite made it clear that TB is an infectious disease; perhaps he didn't understand that XDR-TB could be spread to other people--although how did he think he got it??? TB is a droplet-spread disease. Once an infected person coughs out bacteria, it's fairly easy to spread them to other people. Even though this man had "clean" sputum, up to 17% of people contract TB from patients with no red snappers in their sputum. Perhaps that wasn't made clear to this guy.

I can almost understand him leaving the US to get married. I would personally like to take care of my health first, but I'm sure this guy had dealt with TB before and didn't think it was a big deal. I also realize weddings aren't cheap and his fiancee would probably have killed him if he didn't go to Greece. Okay.

It's what happened in Europe that gets weird. This guy is saying he doesn't know what changed while he was on the flight--if he wasn't contagious before, he still shouldn't be. The problem was never that he was totally UNcontagious--nothing's 100%--but what changed was the threat he posed to others if he were contagious. It would be akin to having sex with a person with HIV and using a condom, but later finding out the person has multi-drug resistant HIV. It makes the risk of contracting the disease that much scarier. Actually, to continue my analogy, it would be like that person having sex with 400+ people, because there were that many people on one of the flights this guy took. Just because the chance of infection is very low doesn't make it zero, and statistically the more people you cough on the more likely one of them is to catch TB.

While I can almost understand him boarding the plane to Europe, I have a harder time understanding boarding the plane home, fully knowing his diagnosis and the danger (even if it was small!) he posed to his fellow passengers.

It's super creepy that Border Patrol didn't catch the guy, even though his passport was flagged.

Unfortunately, the whole thing has assumed a "he said, the CDC said" kind of air, and we may never fully know what actually happened. What is more unfortunate, however, is that so many people were endangered--some who don't even know it yet--who are now anxiously awaiting the results of a PPD.

It does bring an ethical question to mind: Did the CDC have the right to quarantine this guy and take away all his freedoms in order to treat his TB? The libertarian in me says perhaps not. The medical student in me says XDR-TB is a pretty serious thing--for the good of everyone else, we need to get this guy treated. (The geek who loves microbiology in me is simply saying 'Woo, bacteria!', but that's beside the point).

If I become one of the 20% of medical students* who convert their PPD to positive per year by working in the county hospital, you'd better believe I'm not getting on an airplane if I have a positive chest x-ray.

*An entirely made up number I heard somewhere from a cousin of a friend of an ex whose sister had hair.