Thursday, December 11, 2008

Diagnosis - Confusing Confusion - NYTimes.com

The middle-aged man writhed on the gurney in the E.R. His eyes were squeezed shut. Low moans emerged from his parched lips. His sister and brother — the only members of his large Polynesian family who lived here in Portland, Ore. — tried to comfort him, but worry was etched deeply into their faces. Dr. David Peel, the emergency-room doctor at Providence Portland Medical Center, was also worried. This 53-year-old man had a fever and excruciating pain in his back. One leg was weak and he was confused. But the scariest part of all was that the man had been discharged from this hospital just three days earlier after being treated for the exact same thing.

Peel quickly reviewed the records of that first weeklong stay in the hospital. The patient, a smoker, had a history of diabetes and high blood pressure. He came in confused and with a fever. During that admission, the medical team thought he had an infection in his brain, an encephalitis. His white-blood-cell count was high, which was consistent with an infection, and his spinal fluid was abnormal, suggesting inflammation. In addition, the amount of sodium in his blood — an essential mineral and one that is tightly regulated by the brain and the kidneys — was dangerously low, a condition known as hyponatremia. Infections can cause low sodium. So can severe vomiting and diarrhea. And both the encephalitis and the hyponatremia can cause confusion. The team put the patient on powerful antibiotics and was replacing the missing sodium. Treat both, the doctors thought, and the confusion should improve. But it didn't. His fever went down; his sodium went up. But his confusion remained unchanged. He still didn't know where he was or why he was there.

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http://www.nytimes.com/2008/12/07/magazine/07wwln-diagnosis-t.html?ref=magazine