Like many colleagues, I have had numerous patients over the years whose situations, or they themselves, have provoke total recall once mentioned. For me, one of the most formative came near the beginning of my career, in 1991; I remember every detail.

RED FLAGS

I was recently out of fellowship and in private group practice. We received an emergency call on a Saturday evening. A 35-year-old woman reported a sudden onset of painful vision loss and possible irregularity of her pupil. I’m no neuro-ophthalmologist, but it certainly sent up many red flags and I immediately met her at the office.

The patient was calm and cooperative and had significant vision loss in one eye and significant anisocoria with an abnormal light reflex, though not an afferent pupillary defect. She also reported severe headaches. Anterior segment exam and retinal evaluation were both normal OU. IOPs were in the teens. There was no papilledema or peripapillary hemorrhage, but I talked myself into some pallor of the optic nerve in the eye with decreased vision and the larger, poorly reacting pupil.

UNEXPECTED RESPONSE

I called the ER and requested a stat scan, telling the unit clerk I would be accompanying the patient to the hospital in case this obvious neurologic emergency continued to worsen acutely. I was put on hold. Then the nursing supervisor picked up the phone and said, “By any chance is your patient’s name ------?” I said, “Yes, we have no time to spare as her condition could be life-threatening.”

Her response was uncontrollable laughter.

The nursing supervisor told me that this patient was a regular, sent in with the same set of symptoms by numerous unsuspecting, often new ophthalmologists, and she had been scanned countless times. Indignant, and certain that my exam was different, I insisted that she go through the ER for a CT. The staff, I think, humored me, and the patient’s testing was normal and she was sent home.

THANK YOU, TEACHER

In the following days, I learned every local hospital had a chart on this woman a foot thick, and by court order she could be denied hospital access because of her extraordinary abuse to the hospital system and her malingering. Most likely, she had long-standing amblyopia and an Adie’s tonic pupil but had learned exactly which symptoms to report to get immediate attention.

I never saw that patient again yet quietly have thanked her many times for teaching me two vital lessons. The first is that some patients malinger. The second: trust the experience of others, which has saved me time and the health-care system dollars.

May the brand-new clinicians to whom she has turned to over the years learn the same lessons. OM

If you have a memorable patient encounter to share, contact chris.bahls@pentavisionmedia.com.