Lesson of the Day: Always Listen to Your Patients

Even if they are crazy ...

This Tuesday I was on call.  That means that I, along with my team, hung out in the Emergency Department and admitted all the patients in serious enough condition to stay in the hospital.  My assignment for the night was to admit a lady who we'll call Ms A.

Ms A came in at 6am that morning for a chief complaint of sudden blindness.  Her estranged husband (who just so happens to live in her back yard) brought her in.  When I strolled in the room he flashed me a toothless grin and told me his ex-wife wouldn't wake up yet.  I glanced over to the patient and realized she appeared quite sedated.  I'll later tell you why, but for now let's move on with the story ...

I had to get the story from the grinning ex who lived in the back yard since my patient was obtunded.  He told me that last Thursday she came to the hospital for outpatient excision of "skin cancers".  As I look over to her I notice she has multiple sutured lesions on her face.  After the surgery all was well and they sent her home.  Well a few hours later she started getting sick at her stomach and came back to the hospital.  Lo and behold, they did some blood work and she had pancreatitis!  So obviously she got admitted and underwent the standard treatment for pancreatitis.  While in the hospital, records indicated she had been a bit "hesitant" about going home, and at the time of discharge kept telling everyone she had a bad headache.  As some in our patient population seem to enjoy their stay and free meals in the hospital, I think this statement was ignored and she was sent home.  

A few hours later that night, around midnight, she suddenly gets very nauseated and begins vomiting.  She calls the ex from the backyard and out of the blue, she suddenly goes blind in both eyes!  Everything was completely black!  Now let me tell you friends, if you havent figured this out for yourself, sudden blindness is not a thing that usually happens.  And especially not in both eyes at once.  The story continued on per toothless ex, "well she just kept throwing up and saying she had this headache and couldnt see nothin!  Then about 30 minutes later all the sudden she could see again!  But she said it was real shadowy.  Then about another 30 minutes later she went blind again!  So a few hours later I decided to bring her in because I kept giving her Lortabs and they wouldnt work."

At this point, I had already been told by the ED staff that this lady was crazy.  Her ex had also reportedly told a nurse she was crazy.  And this story was crazy!  Blindness that got better and then came back again in a few hours and not deciding to go to the hospital for 5 hours afterward just wasn't coming all together for me.

But then the story gets more interesting ...

At this point, the ED staff decided to get a CT (cat scan) of her noggin.  Sometimes a special type of "mini-stroke" can present with blindness, though not necessarily in the way that this patient did.  Of course to no one's surprise, the CT came back normal.  They then called neurology because they didn't know what to do with this woman.  They suggested an MRI, because that usually gives you better pictures of the brain.

So off to the MRI Ms A goes.  She keeps mentioning she's nauseated (and oh by the way her sight is fully back now) and the nurse goes down to MRI to take her some nausea medicine.  As he hands it to her, Ms A stiffens her whole body, and then has a grand mal seizure.  The nurse witnessed the seizure, but others who saw it thought it was a pseudoseizure.  Pseudoseizures are non-epileptic psychological seizures (aka, the patient is faking it).  She was treated for a seizure regardless (hence the sedation I mentioned earlier) and was administered a test to see if she had a seizure or not.  And that test was normal.  Suspicions again grew.

While Ms A was knocked out from her medicines, we decided to sneak her into the MRI to actually see if anything was going on in her noggin.  MRI's take a while to get back, and so our team went upstairs for dinner.  It was interrupted by a call from the radiologist saying we better take a look at this MRI.  It looked like this:

See those white splotches at the bottom?  That's not normal.  And this is the area that controls your vision.

And then on top of that, add this picture to the same one

See that white spot in the middle popping out at you?  That's not normal either.  This is a picture from the internet, but her white spot was even bigger.

Uh oh.  We've got trouble. Now we all felt pretty terrible that we thought this lady was "malingering", or exaggerating/creating symptoms for personal gain/attention/sympathy.

After seeing the images and debating over what they meant/how they got there.  The top ideas were malignancy (especially that middle white spot), a stroke (either spot, but neither of them really screamed a stroke to the radiologists), or an interesting syndrome called Posterior Reversible Encephalopathy Syndrome, which she had all the symptoms for.  We wound up treating her for the latter, and then during her hospital course we wound up ruling out everything that we thought of.  She went home today stable, but still without answers as to what is going on in her brain.

Ill probably never know how things turn out for Ms A, but I did learn a valuable lesson from her.  Sometimes in the healthcare field it's pretty easy to become jaded and maybe even a touch cynical.  A lot of patients seek drugs, and a surprising number of them may exaggerate their symptoms, or even fake their symptoms for various reasons.  But just because a patient may be odd, or you are suspicious of their motives doesn't mean that they can't be very sick too.  If someone tells you they are sick or in pain, you can never ignore that and write it off as insignificant.  Not only did I learn what Posterior Reversible Encephalopahy Syndrome meant during the past few days, I also learned to truly listen to your patients, to not make judgments, and to not jump to conclusions.  A good lesson learned.