For several years, the man takes over-the-counter sleeping pills to get better rest at night. When he runs out of medication, he feels bad: He suffers a seizure, in which he loses consciousness. At the clinic in Hong Kong, doctors diagnose that he is suffering from withdrawal symptoms.
During hospitalization, it is striking that the man is plagued by paranoid thoughts. His heart is racing, he is short of breath and shaky. He is referred to psychiatry. There, the doctors come to the conclusion that the patient has an acute transient psychotic disorder. After receiving two medications - risperidone and citalopram - the symptoms resolve quickly. He is released from the clinic, after a while he can stop the medication.
However, four months later he is re-admitted to the hospital with psychotic symptoms and anxiety. Again he gets risperidone and citalopram and recovers. Two weeks later he leaves the clinic. He now takes the drugs permanently, the doctors report in the journal "East Asian Archives of Psychiatry".
A good six months pass before the patient feels so bad again that he seeks help in the hospital. He hears voices and feels watched. His heart is racing, he is sweating, trembling, short of breath and he is quickly exhausted. The 53-year-old has an anxiety disorder, say the doctors. They prescribe a so-called benzodiazepine, which has a soothing and anxiolytic effect.
On the third day in the clinic, he faints
But this time, his condition does not improve. On the third day in the clinic he faints while walking to the toilet. He comes back to himself quickly.
The doctors now look again exactly how the man is. He is not afraid, but sweats and is short of breath. His heart is racing, his blood pressure is low and there is not enough oxygen in his blood.
When breathing, there seems to be no problems. An electrocardiogram of the heart shows a so-called sinus tachycardia as well as a right thigh block, ie a disturbance in the conduction of the electrical signals through the heart.
A blood test shows that the troponin level is elevated, suggesting a heart attack. Also increased is the so-called lactate dehydrogenase, which may also indicate an infarction. In addition, more white blood cells in the blood than normal. Another investigation reveals that the blood is acidified. The liver works normally.
A computed tomography (CT) of the head and an X-ray of the chest are inconspicuous. However, a contrast-enhanced CT scan shows the man has pulmonary embolism: a clot clogs a pulmonary artery.
The right half of the heart, which pumps the blood through the pulmonary vessels and had to work through the embolism against a greater resistance, has widened. The right thigh block observed in the ECG fits this finding.
The doctors start with a so-called lysis therapy: they give the patient drugs that are intended to dissolve the blood clot. He also receives heparin, which counteracts the blood clotting. Citalopram and risperidone will be discontinued for the time being.
Earlier diagnoses obscured the picture
Three days later, his left leg swells, it is warm and hurts. Ultrasound doctors discover a so-called deep vein thrombosis, so another clot. You again give him an anticoagulant drug to dissolve this clot.
Unfortunately, even now the patient is not on the way to recovery. He suffers a cardiac arrest and needs to be resuscitated. The doctors implant him a pacemaker.
On the advice of psychiatry, the man gets again a drug that promotes his sleep and reduce his anxiety.
In the following two weeks, he gradually recovers, so that he can finally leave the clinic. He goes regularly to check-ups in psychiatry. Neither the anxiety disorder nor the psychotic symptoms reappear.
The doctors write that in retrospect his last episode clearly differed from the previous one. They should have said earlier that this time there was not a psychological but a physical cause behind the symptoms - but the earlier diagnoses would have distracted them.
It is possible that the patient's first attack, when he fainted, was due to pulmonary embolism. However, that can not be clarified in retrospect.
