There is nothing worse than trying to see through the craziness of people to determine if they are really sick – or just having a flare of nuttiness.  Kinda like how it’s so hard to deal with drug seekers – because you know they are seekers but perhaps just this once, they actually have something “real” going on.

People that are all anxious and nutty are very hard to get a history from. They exaggerate things, they leave out important things and over-emphasize things that are unrelated. They may have tachycardia and other objective findings that could indicate a serious underlying medical process.  I personally consider diagnosing things in these people, without taking a shotgun approach to all of them and ordering mega-workups, to be one of the most challenging aspects of my job.

Recently we’ve had a string of crayzee young women (not sure why it’s just women) who’ve been though giant workups for abdominal pain and vomiting.  You name it, the study has been done on them.  CT’s, Ultrasounds, EGD’s and Colonoscopies, extensive blood testing, seeing “peristalsis specialists” (I did not even know they existed) have all been done and nothing concrete is found.  Clearly there is a psych component to many of these patients and a few are overt drug seekers.  Their management is very difficult since they come in screaming, wanting drugs, retching everywhere, demanding calls to their specialists, hitting the call be q5 minutes, etc.   The other day, I felt like I was diagnosing a new one with this ill defined psycho-motility-reverse peristalsis syndrome.  The sad thing is that she was only 17.  She had all the personality characteristics of it – melodrama, dying swan, Scarlett O’Hara-esque, etc.  She’d had several episodes of the symptoms before that had always resolved after a day or so but  but came into the ER for the first time on that evening.   I almost decided just to do a few blood tests, give some meds  and re-assurance and then refer her for outpatient work up. However, I felt I was able to tease a little INVOLUNTARY guarding out of her from her otherwise histrionic abdominal examination.  I said to myself – “I’m going to order a CT and it’s probably going to be negative and I’ll have given her unnecessary radiation”.  But I just felt that little spidey-sense tingling.

Anyway, I signed out the case to the overnight doc when I left at 1am, telling him “I think we have a new Mary Smith * on our hands”.   I was sure it was going to be negative and that he’d have trouble getting her discharged. The annoying co-dependent mother that was with her did not help the situation. Well, imagine my surprise when I saw the doc next and he told me she had a big fat case of appendicitis!   I was like “Thank God she had something real that was solvable!”  Who knows, she might be back with nonsense but hopefully not.  Hopefully her nuttiness just came out because she had a real problem.  Never ignore your spidey sense.

* – the fake name of a regular cyclic-vomiter that comes in every week

Me: ‘OK Sir, you have a pretty bad infection on your penis called balanitis -  It’s probably because you were not taking your antibiotics and doing dressing changes as prescribed by your doctor after your circumcision.”

20 year old Pt: ” Yeah, that was pretty dumb of me I guess”

Me: “Anyway, it should go without saying that you need to abstain from sexual intercourse”

Pt: “How bout if my girlfriend wants to just give it a little kiss?”

Me: “If your girlfriend wants to do that after she sees what it looks like, she probably needs a psychiatric evaluation.”

I am a professional. I am used to seeing disgusting things and I sympathise with patients who are embarrassed about their appearance, behaviour, or other problems that got them into the emergency room.  However, that does not mean I ENJOY seeing disgusting things. That does not mean that I might not feel waves of nausea or have my stomach turn over when I see something.   This is especially the case when people have no modesty.  No sense of concern for what I am seeing.

Anyway, If you are a woman of 63, are basically built like Mr Potato Head (big beach ball like trunk and spindly legs and arms), are only wearing old, raggedy underwear and a night gown that you may have inherited from your Great Grandmother, and I ask you to roll over so I can see the rash you are complaining about, PLEASE don’t flip onto your stomach and then get into a doggie-style position on the stretcher.  Just, pull the sheets up to your crotch, log roll onto your side, and show me the rash. I now have this very disturbing image in my head that won’t leave 48 hours later.  Kinda like when you hear an annoying song like this.