The triage note read, “Hit by front end loader yesterday on construction site; today can't walk."
The man was in his mid 40s, short but built like a Mack truck, in dusty work clothes. I observed him walking back to the bed without any assistance or obvious problem. “Can't walk" seemed eliminated from the list, and his credibility suffered its first strike. His short stature required that he hop up to sit on the stretcher. No problem there either. I asked the nurse who had triaged him to help interpret; they both spoke Spanish.
The day before, he had been shoveling dirt when the bucket of an earth mover bumped his back. It had not been hard enough to knock him down and he had finished his shift. Since then, he had experienced increasing difficulty walking and was convinced this minor injury was the cause.
I thought to myself that this mechanism wasn't severe enough to cause a spinal injury, and he would have been brought in by EMS the day before if it had. Was this a worker's compensation scam? Credibility strike two.
His exam was normal, and he had no marks of trauma anywhere. He had reported trouble walking, so I asked him to walk for me. He had picked up on my tone of skepticism. He hopped down and threw himself to the floor in dramatic fashion, writhing while holding his back. Clearly, he was malingering. Credibility strike three.
I got a spine x-ray, which was normal, then wrote his papers up for discharge. I put the clipboard in the “needs Spanish" pile. Later, a Spanish-speaking tech approached me, pointing at my guy: “Doc, he wants to know why he's been peeing blood for two weeks."
“That guy? I wrote his discharge order two hours ago! Why is he still here?!"
“Sorry about that, doc. We don't have enough Spanish speakers today. You want me to discharge him now?"
“Well…uh…no…get a urine sample from him, and let me know the result."
The urine was dark and bloody. I ordered BUN/creatinine so we could image him with an IVP for a kidney stone. Shortly after, I was notified by the lab that his creatinine was 9! An ECG showed peaked T-waves, and his potassium was also 9. It turned out he had acute glomerulonephritis of unknown cause. He required emergent dialysis.
Our patients often feel the need to explain their symptoms, and they have often established a causal relationship where none exists. I had incorrectly assumed that he was there for secondary gain because his story didn't make any sense. His weakness was from hyperkalemia, not trauma. This case taught me to work backward from the symptoms and formulate my own conclusions about whether the patient's explanation was correct.
His obvious malingering was an attempt to convince me there was something really wrong, but I failed to recognize that. Malingering and real pathology are not mutually exclusive!
And beware the “oh, by the way, doc" cases where you think you're finished, but you're really not. Luckily for me, I addressed his “new" complaint rather than blowing him off. He obviously would have died if I had discharged him.