Jaded Patient; More Splenic Issues

I was running through a history and physical on a consult before my attending got there but it was truncated to just a history. The patient was a poor historian, not giving very detailed information even when I would ask the most focused questions, and ultimately saying she was tired of questions and did not want me to examine her. Part of the problem was that she has had more operations than she cared to or was able to recall. I think the real problem, though, is probably psychiatric. She has the demeanor and body habitus of one who is poorly motivated and tends toward depression. With mental stress can come physical manifestations of that stress, i.e. somatiform or factitious disorders. It's difficult, though, because while she seems concerned with tallying up vague medical issues, she could be someone who has been dealt a poor hand medically, has needed much treatment just to live somewhat normally, and is not interested in wasting time dwelling on thoughts of an unpleasant medical history.

She insists that during her last operation (2 years ago) either something was left inside her or some other complication arose. She has had a low-grade fever since then and mild pain in the region of the procedure, both of which have been documented on a previous hospital visit. She said the pain flared to a significant level recently, so she finally sought treatment. My attending looked at her CT, asked her a few clarification questions, did a physical exam, and decided that there was no indication to do even an exploratory procedure on her. He said if something had been left in her, there would be evidence on CT: a layman could spot an instrument, and sponges have radiopaque elements in them for ease of visualization. Her symptoms and physical exam are not consistent with any process amenable to surgery. I got the feeling that even with a magic procedure that could cure her pain, she would still have a complaint up her sleeve, which is one of my red flags that there is more than just a physical medical component to a patient's presentation.

The other case mentioned in the title is a man with sharp left upper belly pain for several days. He had a low-grade fever and unproductive cough for the week prior, which he thought was unrelated. His spleen extended 2 cm below the rib cage. My attending asked me what can cause fever and unproductive cough; I couldn't think of an answer, but he said to look up Mycoplasma pneumoniae and autoimmune hemolytic anemia. M. pneumoniae causes pneumonia with a dry cough and fever, and can cause transient cold agglutinin-mediated attack of the red blood cells, leading to transient splenomegaly, which can take longer to resolve than the hemolytic anemia. My attending suspects this etiology, so he has added an M. pneumoniae test to the large battery of tests the internist has already ordered. The surgical treatment for splenomegaly with hypersplenism (overactive spleen chewing up red cells, white cells, and platelets) is splenectomy, but as my attending is fond of saying, a monkey can operate, but it takes a surgeon to know when not to operate. We should find out tomorrow whether Mycoplasma is to blame, and can hopefully give the patient a better idea of what the future holds.

Scott