Hypochondriac Patient? How to deal with the unknown?

[CanuckStudent]

Hi everyone...

I have a Resident in an assisted living LTC that claims to be in constant pain and requests pain control every 4 hours like clock work.

She has been examined by multiple doctors and had every diagnostic test known to man, all of which found minimal (if any) pathology of any kind. She was found to have a small benign growth. She has been on multiple trials of multiple Rx's, including antibiotics for "suspected" UTIs.

Her most common complaint is of abdominal and inguinal area pain. She was complaining of burning and tingling in her arms and legs when I first began working with her. I suspected a B12 deficiency, among other possible reasons, but according to her paperwork from her recent stay in the hospital, all suspected causes checked out.

She has been to at least 4 doctors in 4 months, and has "fired" all of them. She has found one that is putting her through further testing, and she seems to be happy with him...for now.

Until recently, I have always taken her complaints very seriously, as I feel one should when they are dealing with anyone in their care. I would be offended by my coworkers, who called her a "hypochondriac" and say that she was simply addicted to Tylenol.

Looking at her chart and seeing her hx of TIA, I assumed it was entirely possible that she had PAD, which could possibly explain her severe leg pain. It was certainly *possible*. I considered cramping due to mineral deficiencies, and of course, a B12 deficiency. All results were within normal range, but I had no data to rule out PAD. There are other possible causes as well of course.

The point was, everyone else dismissed this lady's claims of pain, which I thought was unprofessional and even dangerous. Even those who call wolf can end up really needing help.

Normally when I work with this woman, she is moaning and groaning asking for pain control every 4 hours like clock work. She is given Tylenol PRN in addition to her regular HS meds (I work the night shift).

To me, it seems like she is genuinely in pain.

A few days ago, she was NPO overnight to prepare for her scope. Each time I checked on her, she seemed fine. She mentioned that she knew she was to avoid Tylenol/more than a sip of water if possible. I found it strange that she seemed perfectly fine, but thought that perhaps she was having a "good" night.

2 days later, I saw that her room was rearranged. It had never crossed my mind that SHE had done this herself. I was told this the next morning. I though this was odd, considering that she is supposedly always in so much pain. Of course, she was calling me for Tylenol due to "severe back pain" that night.... Odd no matter how you look at it...

Last shift she complained that she could not empty her bladder, and had severe pain. It did feel like her bladder was distended and full. Her vitals were within normal range, and she didn't have a fever. She had just finished her 3rd course of antibiotics a "suspected" bladder infection.

She again appeared to be genuinely in pain, but for some reason, near the end of my shift, I couldn't help but wonder if this whole time she's been "faking it". It's not going to affect my interactions with her of course, or her care, but I want to know if I'm being naive or doing the right thing by taking her more seriously than my coworkers. I want to make sure she is getting proper care, but I don't want to be getting sucked in either....

Can anyone here comment or give me some advice?

[CanuckStudent]

To clarify, the Resident was able to void before my shift ended (I thought she'd need a catheter, which I am not authorized to insert). She still complained of pain however and said she would be going to the hospital in the a.m. I have not been back to work yet, so I don't know if she ended up going or not...

[Laught3r]

Does she have many visitors? Is her family involved with her care? Does she interact with the other residents? Is mental health involved in her care? Sometimes when I see residents that have many complaints of health issues and multiple tests and doctors cannot find reasons, I start to think about social and mental reasons. Just my humble opinion.

[CanuckStudent]

Does she have many visitors? Is her family involved with her care? Does she interact with the other residents? Is mental health involved in her care? Sometimes when I see residents that have many complaints of health issues and multiple tests and doctors cannot find reasons, I start to think about social and mental reasons. Just my humble opinion.

I agree that she could be lonely, but she does have at least one son that she sees often. I am not sure about how she interacts with others during the day, since I work only nights. I do know that her husband passed away awhile ago, and she likes to talk about him, so I ask her questions about him a lot. This seems to make her happy.

Mentally, she is not *officially* dx'd with anything, including dementia, etc. Or at least it's not on her chart at our facility.

But very good insight, and I agree that it really may be a factor that is not physiological. But I want to be sure.

Any advice? Should I continue as I always have and simply be compassionate, or should I question her further to see if she is simply lonely? How do you approach the issue and get results without offending? If it does appear as though she really may be a hypochondriac, should I investigate that further?

Thanks for your help!

[canoehead, BSN, RN]

What does her son think? This may be the way she always has communicated.

[ERNurse03]

I wouldn't investigate anything. It sounds like she's had a battery of tests already and the doctor's aren't finding anything. The only thing you really need to do as a nurse asside from the doctor's orders is give this lady emotional support and alert the doctor if you see changes in her condition that may indicate something is wrong.

[nightmare, RN]

Has this lady had a stroke? There is a condition called post stroke neurological pain which causes tingling and burning usually in the affected side.It is very difficult to treat,even morphine does nothing for it,drugs like Amytriptiline help. One of it's weirder symptoms is that the patient can be sleeping like a baby one minute and roaring with pain the next.this often causes staff to think that they are attention seekers.

[Erin 321]

Until recently, I have always taken her complaints very seriously, as I feel one should when they are dealing with anyone in their care. I would be offended by my coworkers, who called her a "hypochondriac" and say that she was simply addicted to Tylenol.

When your colleagues declared her addicted to Tylenol, you did remind them that Tylenol is not an addictive substance, right? This is the second time this week I've seen reference to a patient being addicted to Tylenol and it's simply erroneous. If it's plain Tylenol she's requesting all the time, and not Tylenol with codeine, I wouldn't worry that she's "faking it". Tylenol is not much of a reward for that kind of dramatic effort. Just because we can't identify the source of pain, doesn't mean it isn't there (as you obviously know, or you wouldn't be so conflicted about this). Regardless, it's not your job to diagnose this patient or the source of her pain, although your efforts are admirable. It is, however, part of your role to medicate the patient according to her description of her pain and the orders you have, and to inform her physician if her prn pain meds aren't adequately controlling her discomfort. He can take the lead on making sure she had suitable analgesia and investigations.

Also, does your facility have a bladder scanner, or a more accurate way of seeing if this patient is fully emptying her bladder after voiding? You said you palpated to check this but I'm not sure how accurate that might be. If she isn't fully emptying her bladder, that might help to explain some of the pain, as well as the recurrent UTIs. Good luck!

[Dalzac, LPN, LVN, RN]

When reading this post the one thing I noticed was the q 4 hour tylenol. This drug is so toxic to the liver and if she is taking it so often are her liver enzymes okay? I would be very concerrned about that.

[morte, LPN, LVN]

has she had a small bowel endoscopy?

[Jo Dirt]

This sounds like my mother.

My mother doesn't have dementia either, she is a highly intelligent person (tested to have an IQ of 154, class valedictorian, all that stuff)

but there is no way in the world any doctor or diagnostic test can convince her she doesn't have terminal heart disease, terminal colon cancer, throat and mouth cancer...it's disheartening to see how totally irrational she is about her health. Woe to anyone who would suggest it is in her mind.

Hypochondriasis is a very complicated disorder that not only affects the quality of life of the individual suffering with the disorder, but it is a total drain on family and friends who are helpless to help someone who can't be helped.

[geek, BSN]

How about Interstitial Cystitis? I had severe bladder pain for a year before I got that dx...many doctors told me they couldn't find anything wrong and turned out I had a severe case of IC.