STARES 3 - Difficult patient with an unreliable history

SITUATION
A 26 year old male presented to ED with vomiting, shortness of breath, a cough and chest pain. He was admitted to the ward with pneumonia, with the aim of having a psychological review. His past medical history included borderline personality disorder. He also complained of weakness in his left side from a car accident two years ago. He claimed it had not gone away but he had been managing. He said he could hardly stand as he was so weak on that side he would fall over. Nursing staff had been helping him transfer and ambulate. He was being assisted with showering and activities of daily living (ADLs). There was evidence however that what he told hospital staff was not accurate or reliable. For example, while he claimed to be too weak to stand, nursing staff had witnessed his walking around his room independently when he thought nobody was watching. Similarly, he told the physio he had vomited in the shower, however the nurse was helping him shower and she stated he had no vomited at all. His notes indicated he was not as sick as he wanted everyone to believe (and possible believed it himself).

TASK
My task was to assess and treat this patient without reinforcing his behaviour.

ACTION
While taking a subjective history I asked about his cough and shortness of breath. While I took note of his answers I needed to weigh them up against the objective evidence. Although he claimed to have shortness of breath at rest, and was claiming to cough up black/brown sputum, I could find no evidence to back this up. There was no indication of shortness of breath at rest and no increased work of breathing. His oxygen saturation was 100% on room air. On auscultation his chest was clear and the sputum he coughed up was very minimal and white/clear. His chest x-ray also showed his chest was clear. He claimed in the subjective assessment his left side was very weak, and on manual muscle testing he only scored a 3+ in his left lower limb. It was clear he was deliberately trying to act weak, and when I asked him to stand he was able to support his weight.
I then had to sort out treatment for this patient. While the chest was clear I could not ignore treating this as I had a duty of care to this patient, and he said he was having trouble bringing up sputum. I went through the ACBT with him and taught him how to do it. His cough was dry and non-productive. I then explained he needed to do the ACBT by himself and that he didn't need a physio with him when he did it, I encouraged him to be independent in this treatment. Before I could mobilize him he started deliberate dry-wretching so I stopped treatment.

RESULTS
Through my assessment the chest was cleared, and ACBT was non-productive. I provided education on ACBT to allow the patient to manage any sputum independently. I also provided the patient with a walking stick to encourage him to be independent and ambulate around the room. Unfortunately I did not get to assess the patient's mobility.

EVALUATION
I feel my session was fairly successful as I was able to clear the chest and we no longer had to worry about treating it. I provided education so he could manage any sputum, so in this way I did provide the patient with treatment without making it too passive and encouraging his behaviour. The plan is to review his mobility and then discharge him from physio as he no longer requires our services. It is a psych issue, not for physio. I believe I was effective with my assessment and treatment and found the relevant information, rather than continuing to treat him for many sessions which would be unnecessary.

STRATEGIES
When dealing with this situation the following strategies can help:
1. Discuss with nursing staff to see how the patient is when they are not being "assessed".
2. Compare subjective findings with objective findings to get a clear clinical picture, especially if the patient seems unreliable or a poor historian.
3. Don't take everything the patient says as the truth if he has a personality disorder. See what you can back up (either objectively or by asking other staff).
4. Don't use passive treatments as it will likely reinforce their behaviour. Get them actively involved in their treatment.