Previously unrecognized syndromes

Sometimes, my medical education simply fails me.  I look at a chart, talk to a patient, and none of it makes any sense.  That is, it doesn’t really conform to the scientific classifications I came to know and love in medical school.  So, I decided to start classifying my patient interactions according to syndromes that I recognize, but that seem to have been overlooked by the otherwise serious medical establishment.  If we can recognize these, we may be able to free researchers from trying to investigate ridiculous problems that we already know about, and give them more time to work on serious doctor stuff and thing-a-majigits.

1)  Spousal aphasia:  This syndrome is characterized by a patient, typically male, who presents with a relatively minor complaint such as shore throat or ankle sprain.  Subsequently, the patient’s spouse interjects numerous other complaints, such as chest pain, dyspnea, fever and thunderclap headache, to the objection of the patient, who is silenced by the concerned spouse.  “Shh!  Don’t listen to him.  He’s had chest pain all week!   He never tells you what’s wrong!”  Spouse expects you to hold patient hostage until she is satisfied with test results.

2)  Pseudo-poverty syndrome:  The patient with this syndrome suggests that he or she suffers from a total lack of finances by saying “I haven’t been able to see my doctor because I owe her money.  So I came here instead.”  Patients with pseudo-poverty usually are eu-cell-phonic, eu-SUV-ic, eu-jewelry-ic and eu-cigarette-ic.   Frequently, their mobility is limited only by the large pontoon boat attached to the back of their new pickup truck.  Often, their watches are nicer than yours.  They should be encouraged to be embrace their prosperity, and after stabilization should be shaken down by Guido, the exit billing expert.

3)  Failure of reality syndrome:  Typically female, this syndrome involves absolute denial of objective facts.  Something like this:  “Could you be pregnant?” “No”  “Do you have sex”  ‘yes’, “With a man”, ‘yes’, “do you use birth control”, ‘no’, “so you could be pregnant”, ‘no’, “do you complete the act?” ‘of course’  “Do you have all of your parts, or are some missing?”  ‘I have all of them, duh’. “Does your partner (if male) have all of his, or did he have an accident?”  ‘He’s just fine, thanks.’  “Then you could be pregnant”.  ‘No way!’

This patient is often diagnosed with the co- morbidity of pregnancy.

4)  Acute MaMa-sitis:  This patient (also usually male) is often seen in cowboy or biker gear, after engaging  in an altercation over a woman named Chastity.  With police officers at the bedside, handcuffs in place, pepper-spray-reddened eyes and broken hand from hitting someone else (and a brick wall), this patient cries:  “Have you called my mama?  Have you?  Somebody please, I need to talk to my Mama”.  Diagnosis is confirmed by hot girlfriend (Chastity) in mini-skirt, looking at the ceiling,  stroking patient’s forehead and rolling her eyes, wondering where all the men have gone.

5)  Alcohol induced Status-Touretticus:  This patient is, by definition, intoxicated, though seldom by more than “two beers”.  Most prevalent in men, it’s presentation is more striking in petite sorority girls and octogenarian  grandmothers.  Vocalizations are almost poetic in their use of profanity.  “I said, I gotta  ^(*$$% get outta this *#^*&^ place or I’ll *&^% you right where you *@#$% and your *%#^** horse too, you !!$&64!”

Often very fleeting in presentation, when alcohol has been largely metabolized, this patient can be seen apologizing and asking meekly for a telephone and cup of coffee.  An audio-tape of the encounter would be useful, but probably illegal and unethical.

6)  Invincibility syndrome:  This syndrome is fascinating, and defies all of our education in trauma care.  This is the patient who, despite all his or her best efforts, simply cannot die.  May be a member of secret sect known as “The Immortals”, and be seen in trenchcoat, carrying a sword.

Case Presentation: Having wrecked his motorcycle in December, 43-year-old Barry was thrown through the windshield of another vehicle, out the back window and into a stone wall.  He then fell down an embankment into water that was 45 degrees Fahrenheit.  Discovered in the morning by passers by as he stumbled along the road, he was brought to the emergency department blue, shivering and constantly asking for a cigarette.  On further examination, it turns out he received  gunshot wounds to the chest, right leg and left arm at some point during his adventure.  (Of which he has no recollection).  While you are speaking to the trauma team, this patient manages to drag his backboard to the parking lot to find a light and to make lewd comments to members of the local women’s college track team who are waiting with a friend.   Brought back to his room, he lapses into acute “status-Touretticus”  (See above).  Fortunately, his unconcealed rage at the universe helps to re-warm his core, and his insistence on smoking while attached to Oxygen tubing causes a small fire, further re-warming his airway.  He is found to have through and through extremity wounds, and only a small pneumothorax.  When normo-thermic, he is lucid and signs out AMA, because he “has some stuff to do, but may come back later”.

7)  Intractible pain syndrome:  Suffering from every known pain syndrome, this patient has been diagnosed with dystonia, atonia, hypertonia, fibromyalgia, degenerative disc disease, degenerative joint disease, non-stone kidney stones  (the worst kind), gout, cluster-migraines,  interstitial cystitis, proctalgia fugax and a few others you haven’t even heard of in your entire education.  This patient is on high dose oral methadone, in addition to a pain pump and fentanyl lollipops (and patches).  He or she presents to you because the pain is “Jusssst tooo bad too handdelll.  I jutht cantakeitnomoooorrrr….zzzzzzzz.”  This patient wants more pain medicine.  This patient is usually best managed by immediate discharge to home to the care of the long-suffering , exhausted spouse with rescue fantasies.  Or, if you’re feeling spunky, by administration of naloxone.

8)  Fashion crisis syndrome, female:  Believing solidly in his or her own inherent attractiveness to the opposite sex, this patient is in desperate need of help from the gang from ‘Queer Eye’.  This patient (if female) is wearing a red thong beneath her gown, which she intentionally ties backwards. Said thong is invisible, having been swallowed up by folds of skin.  Can also present as young women visiting E.D. in bunny slippers, too sick to apply actual shoes, or as season inappropriate attire (flip-flops in ice-storm, fur coat in August).  Do not make eye contact.  Or thong contact.  Do not look at nurse’s face, due to risk of sudden, explosive laughter.

9)  Fashion crisis syndrome, male:   Patient believes that shaved head and goatee make him look like a wrestling celebrity, that absence of underwear beneath his decades old cut-offs will make women want him and often wears a tank top t-hirt that he audibly refers to as “a wife beater”.  As in , “Mama, hand me my wife-beater”.  He may also wear a hat that he considers ‘tres chic’, but which says something like “Damifino” or “Gimme some of that good stuff”.  There is nothing you can do.  You’re a doctor, not a miracle worker.  If the patient is unconscious, see to it that the hat disappears, forever, for the sake of western culture.

10)  Redneck syncope syndrome:  This patient believes he or she has passed out.  After a motor vehicle accident, when asked about loss of consciousness, the patient will say, “Yeah, I was out for a second”.  When asked about LOC from an altercation, the patient will say, “Yeah, I was out for a second”.  Sometimes presents as emotional overload from argument with loved-one.  In that case described as follows:  “Yeah, I was out for a second”.  Most of us call that blinking.   Patient’s family may describe a longer interval.  “Daddy’s been working double shifts for two weeks, and he was off tonight and drank a twelve pack, and he just up and passed out!”  Most of us call that sleeping.

11)  Acute on chronic aging syndrome:  Really a syndrome of family, in which patient’s loved one’s deny the fact that patient is old and infirm.  For example:  This 95-year-old dementia patient hasn’t said a word or for two years, and only occasionally smiles in response to a voice.  This syndrome in the E.D. is characterized by the same behavior consistent with dementia, however the family is convinced that the patient has recently forgotten how to swing dance and carve wooden bears with a chainsaw.  “She just isn’t acting right.  Sure, she’s always like that, but something is definitely different tonight.”  This is best managed by immediate involvement of primary care provider, for blame purposes. “I honestly wanted to admit your mother to evaluate this striking change in behavior, but her doctor just refused!  I’d call him tomorrow if I were you.  Will you be taking her back to the nursing home, or shall I call an ambulance?”

12)  Familiarity syndrome:  This patient knows you, or your family, or knows that you know their family.  Despite crushed body part or active bleeding,  patient asks things like “Hey, how’s your mom and them?  Didn’t we see you at the Oktoberfest?   You took care of my cousin Robbie when he fell off that horse!  Where do you go to church?”  Requires aggressive sedation or will result in endless banter.

13)  Non-anatomical Migratory Polyparesthesia and Poly-algia Syndrome:  Also known as ‘third shift disease’, this patient has tingling and pain in patterns that do not fit any known physiological or anatomical pattern, except perhaps that drawn by heroin-addicted acupuncturists and phrenologists.  Numbness on left ear radiates directly to pain in right foot, pain in left upper quadrant results in tingling in genitalia,  tingling in right nipple causes sore throat.  It’s kind of like Twister!  Enjoy this one.  You can’t do anything wrong unless it involves TPA or paralytic agents.

14)  Who’s the Patient Syndrome:  It can be hard to tell sometimes!  Pleasant, well-dressed woman on the ER bed is accompanied by man in chair making intermittent gasping respirations with loud interposed grunts.  He is diaphoretic, and lapses in and out of consciousness.  On waking, exhibits dramatic startle response.  Facial tic resembles seizure.  You feel his pulse and start to go for the crash cart.  “Doctor, no, that’s my husband.  Oh, he’s always like that!  I’m the patient, and I think I have an ankle sprain!”

15)  Identity Amnesia:  Patient forgets his actual name and returns with another, but with similar agenda.  Obviously a very frightening entity, and usually associated with some form of chronic pain.  “So, you’re Mr. Betty Louise MacDonald.  Is that right?”  ‘Yes I am’.  “And you have a bulging  disc and are out of Lortab?” ‘Yes I am’.  “I saw you two hours ago, when your name was Roger Boone.  You had a toothache and I gave you some Lortab.”  ‘No you didn’t.  I wasn’t here.  I’m Betty’.   “Do you perchance have a driver’s license?”  ‘No I don’t.  I have no ID.  My house burnt down’.  “Sir, or Ma’am, I can assure you that I saw you on this very shift, in this room.  You’re Mr. Boone”.  ‘No I’m not.  Wow, my back hurts!’  What a tragic disease!  Often, local law enforcement can help this patient to find his identity through fingerprint technology and incarceration.

16)  Springeritis:  This syndrome usually involves an entire family, and has less to do with actual medical problems than with social drama.  “Well, see, we’re all tore up and our nerves is shot because Susan our daughter was out with this boy, but it turns out he was dating  her Mama on the side.  Now, thing is, he had been selling Ice to Daddy, because Daddy was datin’ his sister on the side.  And when we had our Memorial Day party, Daddy and that boy’s sister ran into Mama and him in the camper, where Susan, as it turns out, was making out with guy from the band that was playing and that’s when the shootin’ started.  Call Jerry Springer, fast.

So you see, years after medical school and residency, there’s so much more to learn, and so much more to discover!  Now get out there and discover some syndromes of your own!