An Amended Diagnosis

I must admit I had felt a little smug about my discovery of Elsa Bruegger’s faulty walker. It really seemed like a very logical explanation to her walking into walls all the time. As it happened, her new walker didn’t quite solve the problem. She continued to be off balance and sometimes did seem a bit unfocused, even downright sedated.

Looking back through her record, I came across a mildly elevated ammonia level a few months ago. I remember speaking with her psychiatrist back then about Elsa and a couple of other patients we share, whose routine ammonia levels were mildly elevated. Elsa had a standing order from the psychiatrist for ammonia levels every three months because of her valproic acid (Depakote) prescription for her mood disorder.

All my research has led me to the conclusion that ammonia levels are of little or no value in predicting whether patients on valproic acid are headed for trouble due to the drug’s unpredictable tendency to cause ammonia to build up within the central nervous system. I have come to understand that ammonia levels are only slightly helpful even in assessing a patient with coma or near coma; the correlation between brain levels and peripheral blood levels of the toxic ammonia relate poorly to each other because of how the blood-brain barrier works to keep the chemistries inside and outside the central nervous system separate. Many experts recommend against routine measurements of ammonia levels for this reason.

Watching Elsa fumble her way down the hall, I decided to order an ammonia level “just in case”. It came back elevated – twice as high as it had been ten weeks ago. Her liver function tests were normal.

I ordered her valproic acid stopped and made sure her psychiatrist got a copy of the lab report and my notes.

This week, Elsa is finally walking straight. She is attending her day program, says “good morning”, makes good eye contact and smiles. She also shows more of a temper, but nothing inappropriate.

Maybe this time I finally got it right.

1 Response to “An Amended Diagnosis”


  1. 1 Yolanda (One Family Table) November 13, 2011 at 1:55 am

    It takes great humility to reassess a diagnosis. Thanks for the reminder that a diagnosis is never absolute or finite.


Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s




Enter your email address to subscribe to this blog and receive notifications of new posts by email.

Bookmark and Share

Mailbox

contact @ acountrydoctorwrites.com

RSS A Country Doctor Reads:

  • Doctors as Stewards, is that News?
    Maybe it’s because I grew up in a socialist country, or perhaps I am actually from a different planet, but an article in today’s New York Times left me scratching my head. The article describes how some doctors and medical groups are quietly beginning to consider the cost of treatments they provide or recommend, for […]
  • Simple Bedside Test Trumps Mega-Workup
    The Journal of Family Practice just published an illustrative case of a young woman with severe headaches and blurry vision. After a couple of hospitalizations with non-contrast and contrast brain MRIs, lumbar puncture and exhaustive laboratory testing, the diagnosis was made with a no-cost two minute bedside test, promoted by yours truly in a post […]
  • Miracle or Outlier?
    A story in the New York Times about a cancer patient who wanted to live to see her daughter’s wedding caught my attention. Haider Javed Warraich, a resident in internal medicine writes: As a physician, I never liked the word “miracle.” I preferred to think in terms of “medical outliers.” And yet that day of […]
  • Psychotherapy and the Dodo
    In “Alice in Wonderland”, the Dodo claimed everyone a winner. In many people’s view, every form of mental health treatment is equally effective. Not so, according to new research. Bulimia, for example, is said to respond better to CBT, Cognitive Behavioral Therapy, than other modalities. So when it comes to psychotherapy, it seems the dodo […]
© A Country Doctor Writes 2008-2014. Unauthorized use and/or duplication of this material without express and written permission is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given.