by Barbara Ebel
“Umm, on physical exam, she was a thin female in distress. Her lungs had bilateral breath sounds, her heart was slightly tachycardic, and her abdomen had bowel sounds and was tender all over, especially the right lower quadrant. Our assessment was to rule out appendicitis and keep her NPO, ready for the possibility of an appendectomy and order studies. Except for electrolytes, everything else is pending.”
Annabel looked at Robby who listened attentively while the attending shuffled his feet.
“Dr. Tilson,” Dr. Pittman said. “First I’ll ask you some more questions and then this will be a great case for teaching purposes. On your examination, was her belly soft?”
“I haven’t done that many exams to compare it to, but I would say ‘yes.’”
“Did it hurt her when you pressed, when you let go, or both?”
“She really complained when I pressed it.”
“Did she keep her eyes on what you were doing?”
“I believe so.”
“Did she say if it was always mostly in the right lower quadrant … where it began?”
“I got that impression based on what she told me,” she said, beginning to feel like this was an inquisition.
Dr. Pittman looked around at the other students. “The main symptom of appendicitis is pain,” he said emphasizing the word pain. “Most patients will say the initial pain of appendicitis occurs around the middle portion of the abdomen which it sounds like is absent in this patient’s case. Findings on physical exam can be very specific. There can be guarding, a rigid abdomen, rebound tenderness and pain on percussion. Did you percuss her belly?”
Annabel looked a second at Marlin who looked away from her. “No, sir, I didn’t.”
“Do you all remember what McBurney’s point is from your Clinical Diagnosis class?”
“Yes,” Da’wan said. “And with acute appendicitis, that should be tender on palpation.”
“Very good,” Dr. Pittman said. “And there’s a sign which may indicate an inflamed retrocecal appendix. Dr. Burk, please tell them.”
As Robby’s eyes settled on Annabel, she felt this was going poorly and appreciated his warm eyes on her. “It’s called the psoas sign and you will see it on exams. With extension or flexion of the patient’s right hip against resistance, there will be irritation of the ilio psoas group of hip flexors resulting in right iliac fossa pain.”
“Did Mrs. Douglas have that Annabel?” Dr. Mack asked.
Annabel felt her cheeks redden. She would have done it if he had told her about it. “I don’t know.”
“No, she didn’t,” he added, looking at Dr. Pittman.
“Dr. Tilson,” Dr. Pittman said, “another important part of every H&P, whether verbal or in writing, are the patient’s vital signs.”
Annabel dug into her pocket and pulled out an index card with Sharon Douglas’s vital information and told him her blood pressure, pulse, temperature, and respiratory rate.
“So she has no fever,” Dr. Pittman said, his voice trailing off more like a statement than a question. “Fever is one dependable symptom. Okay, so why do we make a big deal about appendicitis and what exactly is it?”
The students averted his eyes. Even Da’wan didn’t want to put himself on the spot.
“The appendix,” Dr. Pittman said, “which you know from gross anatomy, is a worm-like appendage off of the colon. With appendicitis, it becomes inflamed when bacteria invade and infect its wall. What we don’t want to happen is for it to rupture or abscess or for the patient to develop further complications with peritonitis. The treatment is antibiotics and appendectomy. It seems like an old-fashioned diagnosis and problem, but make no mistake about it and err with caution rather than frivolity. I have seen a patient’s demise due to put-off surgical care.” He rubbed his facial scar and gave them each a look.
Annabel was glad for his teaching and his discussion made her relax. Finally, she felt like she wasn’t under the microscope.
“Has anyone here had their appendix taken out?” Robby asked.
No one admitted to it, so he continued. “Good. Being a patient yourself is not a good way to learn surgery or medicine. But, hopefully, you each get good cases and samples of different diagnoses while rotating here these next few weeks.”
“Dr. Mack,” Dr. Pittman said, “since you’re the resident on the case, please finish the presentation on Sharon Douglas.”
Marlin took his hand out of his pocket. “Sure. She has not had a fever since admission and her CBC results are back from the lab and she has no elevated white blood count indicating infection.’
Annabel cringed. Somehow Marlin had gotten the white blood cell results right before rounds.
“She was negative on physical exam for a psoas sign,” Marlin said, “and I became suspicious after admission that she complained of pain when I had barely yet even palpated her abdomen. Even though she complained of a loss of appetite, nausea, a fever and tenderness, I am suspicious.”
Across from her, Ginny looked at Annabel and then frowned toward Dr. Mack. Annabel felt her nervousness return. Mack was her resident on this case. Shouldn’t she have known his thinking?
“Students,” Robby interjected, “Dr. Mack is editorializing but we always must give the patient the benefit of the doubt about their chief complaint. Like we said, the history is extremely important for the diagnosis of appendicitis.” He carefully looked at each of them, his hands held together in front of him. “Go on, Dr. Mack.”
“I sent for this patient’s old charts which stacked higher than several stacks of pancakes at IHOP. This patient has a long, chronic history of showing up in the ER, doctor’s offices, and clinics with perpetual physical complaints. And a percentage of the time, her whining of bodily ailments gets her admitted to the hospital. It seems like she’s been reading up on surgical diagnoses and has now positioned herself for surgical admissions. She was in the hospital under the medical department’s care last month with complaints of fever, fatigue, alternating chills, and sweating and nausea. Claiming severe joint pain and weakness, she insisted on a wheelchair during her hospitalization and work up.”
Dr. Pittman cleared his throat. “Don’t tell me,” he said, “she told them she had Lyme disease.”
“Precisely,” Dr. Mack said.
“It’s still summertime,” Dr. Pittman said. “A possibility of a tick-borne disease with those symptoms had to be considered by clinicians.”
Annabel couldn’t remember when she felt more embarrassed. Her stomach felt like it was tied in loops like gift ribbon. This was her first rotation, her first admission, her first real presentation, and it was obvious she was one-hundred percent incorrect with her entire H&P. She wanted to go into an empty room, close the door, and cry. And although she continued trying to subdue her feelings for Robby Burk, her foolishness in front of him was like a double insult.
“So, anyway,” Dr. Mack continued, they did a total work up and ruled out Lyme disease. Apparently she wasn’t too happy and asked them to send her to the Mayo Clinic. Which they didn’t.”
“You probably have many more stories like that from her chart,” Dr. Pittman said, “but due to time considerations and the fact that the team is on call, let’s wrap them up. In other words, let’s get to the real diagnosis which I’m sure must have been alluded to by the Medical Department.”
“Mrs. Douglas is a classic case of Munchausen’s syndrome.”
“Munch what?” Da’wan asked.
“Munchausen’s syndrome,” Marlin repeated. “It occurs mainly in 20- to 40-year-old people and more common in those with few family ties and unmarried. It ends up a chronic condition.”
Marlin beamed with spouting off his knowledge while Annabel’s face saddened. Now she felt even worse. The patient had some problem she never even heard of … besides the fact that she never alluded to it in her H&P.
“I’ll explain the rest of it to the students,” Robby said. “Mrs. Douglas is a far cry from our normal surgery patients.
This syndrome is indeed called ‘factitious disorder.’ As you probably surmised, these patients pretend to have diseases or illnesses and can actually cause physical or psychological symptoms in themselves. Don’t get me wrong. These patients are sick. They have a psychiatric disorder or a mental illness. For whatever reason, they are motivated to assume the role of a sick person.”
“Why would anyone want to do that?” Bob Palmer asked.
“Perhaps because they seek drugs or desire tremendous attention and sympathy,” Robby said. “Sometimes they are malingerers and are avoiding work or responsibility. In any case, it’s a shame we must deal with it in other specialties besides psychiatry because they become addicted to medical care. Hence the other terms for Munchausen’s: hospital hopper syndrome, hospital addiction syndrome, and thick chart syndrome.”
“What’s the treatment?” Ginny asked.
“Of course, from our standpoint, surgery should be done with great caution. However, these patients can require surgery just like anyone else so the problem is deciding when there is a real reason.” Robby looked at Annabel, his eyes showing her empathy.
“Treating patients who have this disorder,” Dr. Pittman chimed in, “is extremely difficult. They are the last people to admit they have it. Best to try and get them to psychiatry and, in the interim, be judicious with any invasive treatments yet cautious not to miss a serious medical problem.”
He stopped and rubbed the groove in his face. With a shake of his head, he said, “Welcome to the real world of caring for a diversity of patients. Now, let’s go see this patient.”
-----
As they made their way down the fluorescent corridor, Annabel made a point to stay away from Dr. Mack. The longer she thought about the didactic conversation the team just had, the more irate she became. She looked down and realized someone was tugging at her sleeve.
“Are you boiling mad?” Bob asked quietly.
She didn’t want to confess that so she stared blankly at him.
“I would be if I had been sabotaged like that.”
Relieved that someone else perceived it the same way she did, she nodded.
“Here,” he said. He pulled his hand out of his pocket with a chocolate espresso bean. Giving her a big smile, he handed it to her. “I told you how helpful these were going to be.”
A smile crept over her face. “Thanks,” she said and put it in her mouth.
Up front, Robby pointed to Mrs. Douglas’s room. Dr. Pittman followed him and then everyone else piled in. Before they reached the bottom of her bed, the patient’s hand went straight to her side and her expression changed.
“I was wondering when you were all going to get back in here!” she cried.
“Mrs. Douglas, I’m Dr. Pittman, the attending doctor in charge. I heard you’re feeling rough.”
She grimaced and leaned forward clutching her belly. “Yes, are you here to take me to surgery?”
“For?”
“An appendectomy. But you’re the surgeon.”
“Your other test results should be available soon. But right now it’s looking like you may not need that procedure.” He glanced at the bedside chart, noting her normal temperature.
Her face soured. “That doesn’t make any sense.”
“But like you said, we’re the surgeons. We would hate to do something drastic to you that isn’t needed.”
“Then I have a tear in there somewhere.”
“Highly unlikely. However, no matter what we do as surgeons while you’re under our care, we often need other specialists to help us out. Sometimes we need the internal medicine service on a case because a patient is diabetic. Sometimes we need pulmonary to take care of a patient’s asthma. And sometimes we need psychiatry because often times they can figure out a patient’s aches and pains better than we can.”
“Really? I thought they just dealt with crazy people.”
“Absolutely not. People with difficult past histories, depression, post-traumatic stress disorders and a host of other issues talk to psychiatrists and therapists.”
She lessened the writhing on the bed and looked skeptical.
“I have a bright idea,” he continued. “Whether or not you do go to surgery, why don’t you let someone from their department come by and talk with you? If you don’t want to see them again after that, you can say so.”
Sharon Douglas looked at Robby Burk and Marlin Mack.
“You’ve got nothing to lose,” Robby said. “In the meantime, we can continue your work-up and keep you NPO.”
“Well … all right. As long as I can tell them about the severe migraine headaches I get, too.”
“There you go,” Robby said.
“We’ll write the order, Mrs. Douglas,” Dr. Pittman said. “You try and get some sleep tonight and Dr. Burk, Dr. Mack, and Dr. Tilson will be back in the morning.” He pointed to the door and they all headed out.
Several feet down the hallway, they stopped. Marlin Mack shook his head and chuckled. “Munchausen’s syndrome is a tough nut to crack. Psychiatry won’t get anywhere with her and she’ll drop their help like hot coal.”
“You’re probably right,” Robby said. “But that doesn’t mean we don’t try.”
Annabel thought Robby’s response was applicable not only for this situation, but for most medical situations. As the attending looked at his list of other patients, Robby gave her a glance. His warm eyes put her at ease … as if he wasn’t holding her misdiagnosis against her.
Chapter 6
When the entire group entered Mr. Newman’s room, he peered over his newspaper and smiled. He sat in the armchair next to the window, the last drips of his evening dose of antibiotic going into his IV.
“Well, look at you,” Robby said. “It appears your two primary surgical physicians have taken good care of you.”
Dr. Wallace and Annabel stepped forward, and Brandy shut the IV pump off before it started beeping.
“Only after that one used me for a pin cushion,” he said, pointing at Annabel.
Annabel’s shoulders sagged and she wondered if Dr. Mack was going to chime in. He’d done enough damage to her for the whole rotation.
“Actually, I’m glad she got that IV in,” Dr. Wallace said. “Otherwise I was going to have to start a central line.”
“No thank you, ma’am,” Mr. Newman said. “I know what those are and I don’t want no part of them.”
“You’ve had enough bowel rest,” Robby remarked. “But I bet you enjoyed that gelatin and bullion.”
“It was a stepping stone to the fat burger I’m going to devour when I get outta here.”
Dr. Pittman patted the patient’s shoulder. “You have a good night. I’m taking this motley crew with me,” he said, pointing towards the door.
They filed past the next patient and out the door as Robby’s pager beeped. “It’s the ER,” he said, taking a glance. “That was our last patient and you all have things to do. If we have an admission, I’ll call the next resident.”
Dr. Pittman nodded good-bye and followed Robby.
“I’m going to go put my things in the call room,” Da’wan said.
“Good thinking,” Ginny said, “in case we get slammed.”
“Plus, we’d better pick out our beds,” Bob said.
They collected their bags out of the office but Annabel trailed behind, her heart not into going to the call room. She didn’t want to be here on call, or even on the rotation. They took a fast-paced walk one flight up and to the far side of the building away from patient care. Several non-labeled brown doors faced the hall with numbers on the adjacent wall tag.
“This is ours,” Da’wan said using his little key. Inside was a small area with a couch, table, and an empty counter; there was a bathroom and a larger room with bunk beds on either side.
“Why don’t you and I share one?” Bob asked Da’wan when they walked in the bedroom.
Da’wan nodded and jostled his bag at the foot of the bed. He smiled at Bob.
“That leaves you climbing.”
“It’s okay with me. I’ve looked over things my whole life.”
Ginny searched Annabel’s expression for what she preferred.
“I don’t care,” Annabel said. “I’ll take the top. You probably need more sleep than I do and the bottom will be easier.”
“Not true,” Ginny said. “We’re all in this together.”
Annabel stashed her bag above. She couldn’t wait for this night to be over.
-----
By 10 p.m., dressed in scrubs, Annabel climbed to the top bunk and lay down. But for the next few hours, all she did was toss and turn. The unfamiliar surroundings, the uncomfortable bed, the coming and going of Ginny and Da’wan for their admissions left her wide awake. Yet, mostly, the day’s events still haunted her and then she wondered about her father’s past. What went on in his mind with all the big, difficult cases and situations he had encountered during the years she was growing up? Had he ever gotten as despondent as she felt and wonder if his medical path was even the correct choice? Did he ever feel like calling it quits and leaving neurosurgery behind him? Had he ever felt awkward and stupid during medical school? If so, how did he get through? He was even raising a family during his early training. How had he done it? She never fully realized how hard it was for him and now she admired him even more. He was not only skilled and worked hard at what he did, but he deserved the stellar reputation he had acquired.
The door creaked open, letting a glow of light into the room. Ginny came in and sat on the bottom bunk.
“Unless Bob is awake,” Annabel said, “you don’t have to be real quiet on account of me.”
“I’m awake,” Bob said. “I can’t sleep because I know I’ll be handling the next admission.”
“Da’wan is still with Dr. Mack,” Ginny said. “They are waiting on CT results. And Dr. Burk got paged to see a really sick patient who came in by ambulance.” She pulled her feet out of her clogs and scooted into bed.