A*******s
发帖数: 9638 | 1 一个年轻病人因为右眼失明一天被收入院，他对我说，他今年已经有5次这样的发作了
，在外面的医院被诊断为Devic’s disease。（不知道这个病的请google）
原来如此，hospitalist把他收到医院来是为了给他上激素。
我做了个检查，他声称右眼完全看不见，但我没有看到APD（affarent pupillary
defect）， 看了一下MRI的报告，大脑和脊髓都正常。 我开始疑惑了。
我让他把左眼蒙上，然后问他： 你能不能看到我？ 他说什么都看不见。
我举起一个手指，问他，看到我的手指吗？ 他说看不到。
于是我一声不吭，举起2个手指，他说看不到。 我举起3个手指，他说看不到。 我开始
舞动手指，他还说看不到。
我说，谢谢合作。 |
h**********1
发帖数: 123 | 2 haha,我们最近也收了个病人，minimal responsive, 做了脑CT，ABG 和bunch of
tests,什么都是正常的。不知道是哪个genius,make NPO, 结果立马respond, 都可以在
hallway里晃来晃去。偏偏是这种人，一分钱都不会pay的。想想中国的穷人因为穷的付
不起钱只能回家等死，这不能不说是另一种制度的悲哀。 |
b***u
发帖数: 746 | 3 A老忘检查具有重要诊断意义的捡皮夹征了。
★ 发自iPhone App: ChineseWeb 7.8
【在 A*******s 的大作中提到】
: 一个年轻病人因为右眼失明一天被收入院，他对我说，他今年已经有5次这样的发作了
: ，在外面的医院被诊断为Devic’s disease。（不知道这个病的请google）
: 原来如此，hospitalist把他收到医院来是为了给他上激素。
: 我做了个检查，他声称右眼完全看不见，但我没有看到APD（affarent pupillary
: defect）， 看了一下MRI的报告，大脑和脊髓都正常。 我开始疑惑了。
: 我让他把左眼蒙上，然后问他： 你能不能看到我？ 他说什么都看不见。
: 我举起一个手指，问他，看到我的手指吗？ 他说看不到。
: 于是我一声不吭，举起2个手指，他说看不到。 我举起3个手指，他说看不到。 我开始
: 舞动手指，他还说看不到。
: 我说，谢谢合作。
|
A*******s
发帖数: 9638 | 4 这个病人的可能诊断是什么？
★ 发自iPhone App: ChineseWeb 7.8
【在 b***u 的大作中提到】
: A老忘检查具有重要诊断意义的捡皮夹征了。
:
: ★ 发自iPhone App: ChineseWeb 7.8
|
n*******c
发帖数: 501 | 5 比较感兴趣怎么和他交代病情的？还是直接refer到benpu那里了事
【在 A*******s 的大作中提到】
: 一个年轻病人因为右眼失明一天被收入院，他对我说，他今年已经有5次这样的发作了
: ，在外面的医院被诊断为Devic’s disease。（不知道这个病的请google）
: 原来如此，hospitalist把他收到医院来是为了给他上激素。
: 我做了个检查，他声称右眼完全看不见，但我没有看到APD（affarent pupillary
: defect）， 看了一下MRI的报告，大脑和脊髓都正常。 我开始疑惑了。
: 我让他把左眼蒙上，然后问他： 你能不能看到我？ 他说什么都看不见。
: 我举起一个手指，问他，看到我的手指吗？ 他说看不到。
: 于是我一声不吭，举起2个手指，他说看不到。 我举起3个手指，他说看不到。 我开始
: 舞动手指，他还说看不到。
: 我说，谢谢合作。
|
n*******c
发帖数: 501 | 6 这个办法好，lol
不过有些人的耐力很强，上次看过一个in custody的病人，不吃不喝不动收进来，俺做
神经系统检查，说什么都没反应，直到检查到痛觉反应，一回头，接触到病人凶狠的眼
神，俺那个怕啊
【在 h**********1 的大作中提到】
: haha,我们最近也收了个病人，minimal responsive, 做了脑CT，ABG 和bunch of
: tests,什么都是正常的。不知道是哪个genius,make NPO, 结果立马respond, 都可以在
: hallway里晃来晃去。偏偏是这种人，一分钱都不会pay的。想想中国的穷人因为穷的付
: 不起钱只能回家等死，这不能不说是另一种制度的悲哀。
|
A*******s
发帖数: 9638 | 7 我就说了＂thank you for your cooperation",
我说他没病，他跟你急，你说他有精神病，他更跟你急，所以我让hospitalist来说，
第三者说最合适。
【在 n*******c 的大作中提到】
: 比较感兴趣怎么和他交代病情的？还是直接refer到benpu那里了事
|
n*******c
发帖数: 501 | 8 奔大有机会和大家说说Munchausen syndrome，conversion disorder怎么搞吧，最近好
几个，头都大了...
【在 b***u 的大作中提到】
: A老忘检查具有重要诊断意义的捡皮夹征了。
:
: ★ 发自iPhone App: ChineseWeb 7.8
|
n*******c
发帖数: 501 | 9 就是头大啊，如果是门诊病人呢？让PCP说？
【在 A*******s 的大作中提到】
: 我就说了＂thank you for your cooperation",
: 我说他没病，他跟你急，你说他有精神病，他更跟你急，所以我让hospitalist来说，
: 第三者说最合适。
|
A*******s
发帖数: 9638 | 10 " I don't know why you cannot see, you may see an eye doctor for a second
opinion." Send PCP a copy
★ 发自iPhone App: ChineseWeb 7.8
【在 n*******c 的大作中提到】
: 就是头大啊，如果是门诊病人呢？让PCP说？
|
|
|
h**********1
发帖数: 123 | 11 haha,老大们都不原意上，只好拿我这个小兵来顶，行美其名曰，要training you how
to deal with difficult patients :((
Anyway, 我就告诉他we did this, this, this, I am glad every test turns out to
be negative. We have done everything we can, you are welcome to get a
second opinion from another another hospital if you want. 他自己也知道他在
faking symptoms, 企图要pain meds未果，终于走了 |
a**e
发帖数: 5094 | 12 我们这里一位德高望重的老医生是这样和病人说的"Let me tell you what is going
on.There is nothing wrong with you. All you need to do is get out of bed and
go to work."
【在 n*******c 的大作中提到】
: 奔大有机会和大家说说Munchausen syndrome，conversion disorder怎么搞吧，最近好
: 几个，头都大了...
|
b***u
发帖数: 746 | 13 sorry, bro, was on call on weekend so not able to reply earlier
basically we are talking about couple different psych diagnosis here:
(1） somatoform disorder: conversion disorder is one of those. It is defined
as 'one or more symptoms or deficit affecting voluntary motor or sensory
function that suggest neurological or general medial conditions', so
something like 'peudoseizure' will qualify for it. Note that the symptom is
not intentionally feigned. this is an important differential diagnosis with
Factitious disorder or malingering. Also note 'hypochondriasis' is also a
form of somatoform disorder, those pts believe they have some severe medical
condition despite all the workup being negative, I bet you will see those
pts as well.
(2) Factitious disorder: like say someone intentionally faking symptoms for
'primary gain'---which is a fancy word of 'assuming sick role' to get
attention or care, etc. Munchausen nowadays is more reserved for a severe
form of factitious disorder, like someone does hospitals shopping (
peregrination), talking about fancy stories which might be quite plausible (
pseudologia fantastica)
(3) Malingering: we all know these. faking symptoms for secondary gain (
money, food) 和国内碰瓷差不多. high rate in inmates.
Anyway, all these can similarily give you headache.........
well, you know what the standard psych recommendations for those? normally
we will not suggest to confront them (unless you are concerned about
Mauchausen by proxy, in which a child is endanger), and suggest them to
follow up with PCP regularly (not as many as they want). Meds normally not
effective, some psychotherapy might have limited response. A large
percentage of those patients will have personality disorder, as you can
imagine.
Another thing is, some of those patients might actually have underlying
disease (both medical and psychiatric), so routine follow up to rule out
anything else.
A lot of them also do have needs, social factor plays a big role. so if we
be able to help in that sense, it might solve the issue.
Regarding A+'s case, it can be any of them, I assume A+ is more leaning
towards malingering. But I don't see a clear secondary gain here (maybe free
meal and bed in hospital for couple days, which might be more common in
winter days). So my opinion is more like conversion disorder if anything
significant just happened to him. Factitious disorder will show evidence if
you find multiple ER visits/hospitalization etc (possible in this case as he
had 5 similar episodes). It hard to tell with
limited info here, to find out, a lot of detective work needs to be done.
【在 n*******c 的大作中提到】
: 奔大有机会和大家说说Munchausen syndrome，conversion disorder怎么搞吧，最近好
: 几个，头都大了...
|
n*******c
发帖数: 501 | 14 精神科知识忘了好多了，以前流行的心理分析、暗示疗法究竟有没有用呢？
defined
is
with
medical
【在 b***u 的大作中提到】
: sorry, bro, was on call on weekend so not able to reply earlier
: basically we are talking about couple different psych diagnosis here:
: (1） somatoform disorder: conversion disorder is one of those. It is defined
: as 'one or more symptoms or deficit affecting voluntary motor or sensory
: function that suggest neurological or general medial conditions', so
: something like 'peudoseizure' will qualify for it. Note that the symptom is
: not intentionally feigned. this is an important differential diagnosis with
: Factitious disorder or malingering. Also note 'hypochondriasis' is also a
: form of somatoform disorder, those pts believe they have some severe medical
: condition despite all the workup being negative, I bet you will see those
|
n*******c
发帖数: 501 | 15 德高望重的老医生说话经过特殊培训，俺们不能顺便模仿，lol
同样的话，小年轻一说立马被人轰出去...
and
【在 a**e 的大作中提到】
: 我们这里一位德高望重的老医生是这样和病人说的"Let me tell you what is going
: on.There is nothing wrong with you. All you need to do is get out of bed and
: go to work."
|
A*******s
发帖数: 9638 | 16 There IS something wrong with the patient.
★ 发自iPhone App: ChineseWeb 7.8
【在 a**e 的大作中提到】
: 我们这里一位德高望重的老医生是这样和病人说的"Let me tell you what is going
: on.There is nothing wrong with you. All you need to do is get out of bed and
: go to work."
|
A*******s
发帖数: 9638 | 17 The difficulty on this case is to differentiate if it is intentional or not.
My diagnosis is conversion disorder since I could not prove he did it
intentionally.
defined
★ 发自iPhone App: ChineseWeb 7.8
【在 b***u 的大作中提到】
: sorry, bro, was on call on weekend so not able to reply earlier
: basically we are talking about couple different psych diagnosis here:
: (1） somatoform disorder: conversion disorder is one of those. It is defined
: as 'one or more symptoms or deficit affecting voluntary motor or sensory
: function that suggest neurological or general medial conditions', so
: something like 'peudoseizure' will qualify for it. Note that the symptom is
: not intentionally feigned. this is an important differential diagnosis with
: Factitious disorder or malingering. Also note 'hypochondriasis' is also a
: form of somatoform disorder, those pts believe they have some severe medical
: condition despite all the workup being negative, I bet you will see those
|
