WHY PSYCHIATRISTS ARE PHYSICIANS FIRST
The EMS report was crystal-clear, but Elena’s diagnosis remained opaque even on the day of discharge. Let me explain how this happened. The hospital social worker telephoned at mid-morning, desperate for a same-day outpatient appointment for a woman aged about 50, “a stockbroker or something.” Managed care found “no medical necessity” for another day’s hospital stay now that Elena’s sensorium had cleared with antipsychotic medication. The patient refused to risk a hospital bill after her carrier refused coverage. So she had to leave the hospital NOW.
The social worker confessed confusion about Elena’s so-called “Psychosis NOS.” Toxicology screens were negative. Routine labs showed no uremia, no electrolyte imbalance, no liver disease. Vital signs were stable; temperature was normal. According to the social worker, the treating physicians had no explanation for Elena’s altered mental state. Yes, they had considered a cerebrovascular accident—but a CT scan without contrast was negative.
The radiologist’s report was reassuring. There was “no evidence of intracranial hemorrhage, acute large vessel infarct, or mass effect or midline shift. The cisternal spaces are preserved. The ventricles and subarachnoid spaces are normal in size. The visualized paranasal sinuses and the mastoid air cells are clear. The osseous structures are intact.” No mention was made of the sella turcica, which might have been telling.
In short, Elena’s microadenoma did not show up on a CT scan, even though many prolactinomas can be diagnosed by CT.1 Elena, in her disorganized state, could not provide a coherent history in the ED and the admitting attending abandoned efforts at obtaining an ROS, writing, “not available”; “confused historian.” So no one knew about her pituitary tumor—or its treatment—at the time of admission.
The social worker read me the EMS report: a security guard outside the Stock Exchange spotted a woman circling the big bull, not staggering, but distracted and unable to answer questions coherently. She looked vaguely familiar, the guard said, and was not in a state of disarray, like so many mentally ill people who wander around New York City. So, he called EMS.
According to the ED report, Elena muttered to invisible companions—while wearing a perfectly pressed Burberry coat and otherwise looking like a “financial type.” The ED attending suspected sleep deprivation, perhaps aided by Red Bull, but waited for toxicology screens to rule out excessive Adderall or cocaine use, said to be endemic around Wall Street.
Elena was admitted to the psychiatry unit, where risperidone was prescribed. After a few days, her speech became more organized, and she was able to recall that she had a prolactinoma, diagnosed many years earlier. More recent recall was still spotty. According to the chart, the information about the prolactinoma prompted a curbside consult with endocrinology, which recommended stopping the risperidone, which increases prolactin, and switching to aripiprazole, which counters hyperprolactinemia.
Dr. Packer is affiliated with Mount Sinai Beth Israel and has a private practice in Soho, New York City. Her most recent book is Neuroscience in Science Fiction Films (2015). Her book Mental Illness in Popular Culture is in press and scheduled for release this summer.
1. Marcovitz S, Wee R, Chan J, Hardy J. Diagnostic accuracy of preoperative CT scanning of pituitary prolactinomas. Am J Neuroradiol. 1988;9:13-17.
2. Bakker ICA, Schubart CD, Zelissen PMJ. Successful treatment of a prolactinoma with the antipsychotic drug aripiprazole. Endocrinol Diabetes Metab Case Rep. 2016. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4898067/. Accessed April 6, 2017.
3. Wix-Ramos RJ, Paez R, Capote E, Ezequiel U. Pituitary microadenoma treated with antipsychotic drug aripiprazole. Recent Pat Endocr Metab Immune Drug Discov. 2011;5:58-60.