Grand Rounds Report: Miller-Coulson Academy

by Academy of Clinical Excellence on February 2, 2011


Earlier this month, I had the immense privilege of being the psychiatrist on a panel, along with fellow Miller-Coulson Academy members Roy Ziegelstein (Cardiology) and Steven Schwartz (Surgical ICU), at the recent Medical Grand Rounds.With the expert input of another member of the Academy, Raf Llinas (neurologist), the panel was able to demonstrate several components of effective clinical reasoning.

Disclosure:Scott Wright, Director of the Miller-Coulson Academy, had contacted us three discussants the night before to give us a clue.He said, “I will present a case of a middle age male who was recently admitted to our hospital.”

The format of the round the next day was as follows:Dr. Wright gradually revealed elements of the patient’s story, stopping periodically for commentary from the discussants as the clinical story unfolded.He started by saying that clinical problem-solving exercises are “somewhat artificial” and can be “nerve wracking,” but a “very nice learning opportunity.”He was right on all three counts.It was like a high-pressure game show, except in front of a brilliant audience and a Hopkins dean.

True to his word, Dr. Wright began by asking each of us how we approach a complex patient case.I replied that I listened with an ear to understand whether the patient’s problems are emerging from something they have (biological origin), do (behavioral origin), are (personality origin) or have encountered (psychological origin).Dr. Ziegelstein remarked he always wanted to hear the patient’s story and do an examination, rather than relying on anyone else’s history and exam.Dr. Schwartz said his patients usually are not able to tell their own story, so he tries to look at the big picture, and as a first step, makes sure that airway breathing and circulation are intact.

I’m not going to present the case and the discussion in detail here, but will summarize the experience and encourage you to attend one of these in the future to witness the excitement first-hand.It’s not only an intellectually engaging time, but also one which showcases how to use the wisdom of colleagues.We first heard the chief complaint (dizziness followed by a fall), which raised questions for Dr. Ziegelstein of cardiac problems and for Dr. Schwartz of head injury.Then came the personal history (a never-married, socially isolated middle-aged paint salesman who lives with his sister), which raised questions for me of psychiatric issues.As the case continued to unfold, we learned that the patient began having tonic clonic seizures.The patient said he drank 2-3 shots of vodka daily (which Dr. Ziegelsten advised might be an underestimate).He had abnormal vital signs (elevated blood pressure and pulse) and diagnostic tests (elevated white blood cell count, 1st degree A-V block with left atrial enlargement and right subinsular hematoma on head CT).Although panel members noted these abnormalities, we were not distracted by them and remained open to a range of etiologies for the patient’s presentation, including cardiac, traumatic, neurologic, and psychiatric.

A turning point in the presentation came when Dr. Wright described the patient’s subsequent hospital course which was marked by a fluctuating altered mental status, agitation, and confusion. This is when I got really excited, as these signs, symptoms, and course are the hallmark of delirium: a psychiatric diagnosis.Now we just needed an etiology.Given the report of some alcohol use, the tonic clonic seizures, and the delirium, alcohol dependence and withdrawal seemed to be the most likely diagnoses for this patient.Dr. Wright, then, reported that the patient’s sister estimated his (the patient’s) alcohol use at upwards of 10 shots of vodka daily, these diagnoses became even more clear.With benzodiazepine treatment, the patient became less confused, stronger and could more safely ambulate over the last 5 days of his 10-day hospitalization and was transferred to sub-acute care for additional rehabilitation.

In addition to the Miller-Coulson Academy’s case presentation and discussion demonstrating how to approach a complex patient, how to use the wisdom of our colleagues, and how to avoid being distracted by abnormal test results, it underscored the basic logic of clinical reasoning.Clinicians are trained to recognize the clustering of symptoms, signs and course that define a clinical syndrome.Clinicians and biomedical investigators then proceed to identify the bodily pathology generating the clinical syndrome’s features, with the ultimate goal of finding the etiology (cause) of the pathology.Withdrawal from alcohol usually results in the hyper-alert, agitated, form of delirium, as seen in this patient. This form is more commonly known as delirium tremens (also known as DTs).

 

Margaret S. Chisolm, MD
Assistant Professor
Department of Psychiatry and Behavioral Sciences
Johns Hopkins University School of Medicine


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