We've all had these patients. For what ever reason, they simple do not want to leave.
Secondary gain?
Padding the lawsuit bill?
Faking disability?
Who knows. It never ceases to amaze me the lengths people will go to.
Case in point. A functional gentleman who presented to my service after apparently passing out at work. He swears he doesn't drink, in spite of alcohol in his system, just under the legal limit.
The wife's explanation? The cough medicine she gave him the night before. Because "I wouldn't be with him if he drank."
You keep on believing that missy.
His complaints?
Hurts all over.
Weak all over.
Chest Pain
Head ache
Low grade fever.
Everything is pointing to viral syndrome. I'm pretty confident in the diagnosis.
Unfortunately this bigger gentleman had cardiomegally on chest xray so a cardiac echo was ordered, which was reported as having wall motion abnormality, which then lead to a stress test, which of course was normal.
I told him he could go home. He has a virus and only time will help.
Unfortunately, I get this call from the nurse who says he's sleepy, hard to arouse etc.. etc.
Of course now, my hand is tied.
Meningitis?
An LP is ordered and his discharge is aborted.
Of course the LP comes back normal.
His basic labs are all normal.
He spends another night in the hospital.
The following day, he is weak. Can't move, can't bear weight on his legs.
He has no fever.
I'm thinking, either he has Guillian Barre syndrome
Or he is faking it.
I speak with a neurologist and explain my thoughts. I couldn't elicit lower extremity reflexes so my concern was not unfounded. But the man's demeanor would suggest against a serious illness.
His lack of concern was striking. If your legs went functionless, you would be scared, stunned, anxious. This man had no emotion.
"I'm just weak"
The neurologist agreed, no GBS. A short trial of steroids was entertained for "viral myositis"
His CPK was normal.
Of course the following day minimal improvement.
I told him in no uncertain terms. You have nothing physiologically wrong with you. You can go to a nursing home to get physical therapy. He apparently has no insurance and said he "couldn't afford that".
I'm sure he has no idea his hospital stay is costing more than $1000 a day for 3 meals a day.
The following day the neurologist signed off.
I told him, It's time to go home. We have nothing further to offer.
His response?
OK.
That's not the normal response of someone who claims his legs don't work.
What do I believe the secondary gain was?
Well, I suspect he simply wanted a break from his home life. A break from the wife.
I really do.
What he got was a very expensive hotel room.
I call this irrational malingering.
I wonder what the ICD code on that one is.
V65.2 is the code for malingering
ReplyDeleteThe ICD 9 code for factitious disorder (differs from malingering in that with factitious disorder, the motivation is to assume the sick role for some psychological reason rather than secondary gain)is 300.19
Maybe the patient wasn't consciously faking, in which case the diagnosis is conversion disorder (300.11)
In my training in Cleveland and New Orleans, the acronym WADAO was popular, encapsulating the patient complaint of "Weak and Dizzy All Over."
ReplyDeleteHappy, please don't send these patients for physical therapy. It's just not right to do that to your friendly neighborhood rehab docs.
ReplyDeleteYours in the struggle,
I see this patient nearly every day in my hospital-based practice. Sometimes, I have to whip out "The Standard Orders." See this post:
ReplyDeletehttp://fatdoctor.org/2007/09/23/make-yourself-uncomfortable/
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ReplyDeleteThanks FD for the link. Remember when the residents used to make the med students do the obligatory rectal on admission. Kind of along the same order of magnitude.
ReplyDeleteDr A. Thanks for the heads up.
ReplyDeleteI'm working, but thanks for the heads up.
The whole 24/7 coverage thing in full effect.
Dr Val. I once had a young woman in her 20's who was so obviously weak in the legs due to "non physiological supratentorial" reasons that I discharged her. I had a hospital quality physician AT MY HOSPITAL say to me that the patient COULD NOT GO HOME because of hospital liability. She had PT fooled. She had everyone fooled. I refused to get a neurology consult or further pursue workup.
ReplyDeleteIt was ridiculous. That I was being told I couldn't discharge a patient. When I said she could go to rehab, which I knew was bullshit, the insurance company wanted a medical diagnosis for the rehab.
I said I couldn't provide one.
Needless to say, she didn't go to rehab.
She got a walker and was discharged home.
It never ceases to amaze me the lengths people will go to.
Fortunately, when people like that come to the ED, I tell tell them we are not set up to deal their sort of complicated problems and refer them to a specialist or someone else as an outpatient. Alternatively, I paint an excessively bleak picture of what a hospital admission will be for them - painful procedures, nothing to do, bad food, noise, and expense. It works for a good percent of these folks.
ReplyDelete