Code words

June 5, 2008 at 4:00 am | Posted in Uncategorized | 2 Comments

I was asked to see a patient not too long ago who is a total hypochondriac. Which of course doesn’t preclude actually being sick. And which is why we all hate these kind of patients–we have to work them up as if their complaints could be something real. This particular patient had recently been on the surgery service for a simple operation that was without complications, but stayed three times longer than the average such patient because she kept sabotaging her care. And then she bounced right back with a bunch of vague multisystem complaints, including abdominal pain, so we were consulted as soon as she hit the door. We asked for labs before we would see her, and they showed a set of metabolic derangements that are usually only found in patients who have been starving themselves and abusing laxatives. And, with an undeniable medical but non-surgical problem, and no longer complaining of abdominal pain, she went to a medicine subspecialty instead. But I had to write a consult note anyway.

Here’s what I wanted to write for the assessment and plan:
1. Ha ha! No surgical issues. Sucks for you!
2. Pt crazy: good luck w/dispo. Suggest psych consult.
3. Will follow from as far away as possible.

But of course, you can’t write things like that in the medical record. Not only is it unprofessional, but if you happen to be wrong, you’ve made the error ten times more egregious. So instead you write:
1. Multiple metabolic derangements. Pattern not consistent with a postoperative complication or new surgical issue.
2. Please call with any surgical issues or questions.

However, you can leave clues for the educated eye to see. Because there’s always a treasure trove of craziness in their chart just waiting to be pointed out. Invariably there’s a diagnosis of fibromyalgia. Multiple vague abdominal complaints. Low back pain with a pristine MRI of the spine. And of course, 3 or more allergies.

Although sometimes just one is enough. And on this patient’s allergy list I strike gold:
1. bupivacaine – causes numbness.

Like a big red flag saying “PSYCH CONSULT.”

Or, less likely though still possible, “THE DOCTOR WHO TOOK MY HISTORY IS A COMPLETE IDIOT.”