Friday, April 30, 2010

My first case of Pseudocyesis (2nd of 2 Parts)

There she was, the patient, lying on the IE table.  She had an average build, not obese and not thin.  She was set for the Internal Examination.  The lower part of her dress was lifted up to the waist, her underwear has been stripped off, exposing the sensitive part of her female anatomy, and her feet were firmly positioned on the stirrups.


What overwhelmed me was the flabby abdomen which flattened, as if to pay its respects to the law of gravity,  while the patient was in the supine position.  What is even more overwhelming is the sight of nurses tinkering with the flat abdomen using the Doppler probe.  I know that the Doppler is used to amplify the fetal heart sounds but the sight of the nurses using it on an ultra-flat and flabby abdomen puzzled me for a while.  What are they trying to do?  Are they trying to amplify the patient's bowel sounds using the Doppler?  Those questions flooded my head.


I immediately wanted to ask the patient, "Nang, buntis gyud ka? (Ma'am, are you sure you are pregnant?)"  Instead I asked her when her last menstruation was, one of the questions which I usually ask patients who come in.  "September 2009," came the answer.  That was around seven months ago, I thought.  I asked her if she had regular pre-natal check-ups.  She admitted she was initially seen by a physician, and only once at that,  but she eventually opted to be checked up by a midwife from the rural health center in their place because she lives quite far from the city. 


The nurses handed me the patient's chart and at the same time told me the patient came in because she already felt labor pains.  "Okey," I screamed - inside my head. I tried to digest what the nurse said while I was looking at the nurses who were trying with all their might to capture fetal heart sounds through the Doppler.  I was at a loss for questions.  That was totally unexpected for someone like me who has been admitting pregnant patients for years now.  I looked at the patient's data on the chart.  She's 50 years old.  That somehow explained the skin that was beginning to lose turgor and the lines that marked her face.  Still at a loss, I stared for a few minutes at the nurses who were more like busy elves this time.  Thank God, they surrendered and realized their efforts were futile.  "Wala man gyud mi madunggan, Doc (We could not hear any fetal heart sounds, Doc.)" they declared.


I approached the patient, and asked, "Nang, nagsakit na imo tyan?  Asa man dapit? (Ma'am, are you having labor pains?  Can you point to me where you are feeling the pain?)Okey, that question might sound absurd for you medical people out there, knowing that labor pains are felt on the abdominal area, more on the lower part, and the pain usually radiates to the lower back.  But, I asked it anyway.  Probably the patient read the confusion peeping  from the behind my head, and she told me that her entire abdomen was painful, hovering her hand over her entire abdomen to send her message across.  She was already starting to be confused herself.


"Naa kay napamatian molihok ang bata, nang? (Do you feel any fetal movements, Ma'am?)", I asked.  "Oo, Doc," she replied yes without batting an eyelash.  The nurses and I stared at each other. 


I took a deep breath before I started to explain my side to the patient.  I told her that I will not do the Internal Examination this time because I am not quite convinced that she is pregnant.  In the aim of dispeling any frustration my comment might bring her, I added, "Cge lang, nang ha, naa ta mga examinations na buhaton para mahibal-an gyud nato.  (Don't worry, Ma'am, we will do a series of laboratory exams so we will know her exact condition.)"  I told her, we will be transporting her to the Emergency Room (ER), where I will make the admitting orders.  I paused for a few seconds to pass to allow everything to sink in then I exited from the room. 


I saw the patient again at the ER where I did my Physical Examination on the patient.  Abdominal pain was poorly localized and there were no pertinent findings that would point to pregnancy.  At one point I asked her if she does believe that she is pregnant.  She answered a resounding "Yes."  Later on, she would admit that she never had a positive pregnancy test result but still she went on to have regular check-ups with the midwife at the heath center.


One of her companions is her sister so I called her over for some questions.  I had to be a little direct this time.


Me:  "Ma'am, para nimo, buntis gyud ni sya?" (Ma'am do you think your sister is pregnant?)  I realized this is the second absurd question I asked that time.  God, those were two absurd questions in an hour!.


Sister:  Oo, doc. (Yes, Doc.)  Another resounding yes.  Me No.1 talking to Me No.2:  Doc, don't you ever get it?  Me No.2:  Did the gods just sent me a family of psychotics or something to punish me for trying to sleep early while on duty?  Is this a dream?  Wake me up, please...! 


Me:  Wa mo natingala, nga wa nidako iyang tiyan? (Didn't you ever wonder why her adomen did not grow big?)


Sister:  Natingala pud doc. Kay ang ako anak na iya pag-umangkon, kadungan dungan man to nya ug buntis dayon nanganak na man.  (We were puzzled Doc.  My daughter, her niece, got pregnant at arounthe same time when the patient apparently did, and my daughter already gave birth.)


Then I turned to the patient and asked, "Ikaw, nang, wa ka natingala nga wa nidako imong tyan?"  She answered confidently, "Kay di man pud ko hingaon, doc." (I don't eat a lot, doc.)


 Wow.  I thought and gave out another deep breath. 


Upon further inquiry, I knew, through the sister, that the patient has a foreigner-boyfriend.  The boyfriend is out of the country right now and they are still very much together because the boyfriend still sends money to the patient.  If  that is their idea of togetherness, then I don't have the right to object to that.  My goal then was to know if the patient had any history of mental illness such as depression and the like, or recently went thorugh a life changing event that triggered her to believe that she is pregnant.  Unfortunately, the patient did not have any of those.

I did what I had to do.  I called the Attending Physician to inform her about the admission.  I told her about my impression of the case and I told her about my plans in the management.  We both agreed on the impression of pseudocyesis.  Our plans included a Complete Blood Count, a Pregnancy Test, and a Transvaginal Ultrasound in morning.


The patient was sent to her room and I retired at the Doctors' Quarters.


I was not able to get my much needed sleep when I returned to our quarters.  After about an hour or two, I called the Nurses' Station to ask about the results of the laboratory exams. 


It did not come as a surprise at all that the Pregnancy Test turned out to be Negative.


(Coming up:  Dissecting my first comeuppance with Pseudocyesis)

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