Guest Paula Posted February 17, 2014 Share Posted February 17, 2014 Has anyone had a patient with factitious diarrhea? Is there a way to test if a patient is taking laxatives through stool testing? The physician I work with has a 29 y/o woman with diarrhea and he has ordered every test known to man to try to figure out why. I think she is anorexic and taking laxatives. She has a history of depression, multi drug use and abuse issues and alcohol abuse, along with tobacco dependence. I initially saw her when she established care at the clinic 6 months ago. She was concerned with thyroid issues and admitted to narcotic abuse in which she was in remission at the time. She is very thin, virtually no breast tissue and has issues with amenorrhea. I did an initial workup for thyroid issues and tests were negative. We discussed anxiety and depression issues, counseling and possibly drug therapy with SSRI's. I made her cry but she started on an SSRI but only took them for a week or so. The next time she came in she had a sore throat and cough for 2 days. I did not give her abx. She was upset. The next time she came in was to see the dr. and I have not seen her since. She is in at least 2-3 times a month. He can't figure out why she has chronic diarrhea. I think she has had colonoscopy and Gi consult, more thyroid tests, hormone testing. She will not take any more anti-depressants and is now on xanax. The doc is concerned and thinks he will refer her to endocrinology.. I believe she had an abnormal FT4 test, with normal TSH and T3. I think she is a malingerer and is causing the diarrhea by taking laxatives. But then, what do I know????? Any thoughts? Link to comment Share on other sites More sharing options...
UpRegulated Posted February 17, 2014 Share Posted February 17, 2014 Have you asked her about laxative abuse? Screened her for eating disorders or hx suggesting eating disorder? Given your post and provided history, IBS is very possible, but also hypochondriasis as well. Given what you've provided, endocrinology seems premature. Everything you mention taken together suggests psych consult. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 17, 2014 Moderator Share Posted February 17, 2014 I've seen this too with psychogenic polydypia...lots of diarrhea and lyte issues... Link to comment Share on other sites More sharing options...
whoRyou Posted February 17, 2014 Share Posted February 17, 2014 If I recall correctly most are of high socioeconomic status and many are employed in the medical field. Spooky! Link to comment Share on other sites More sharing options...
db_pavnp Posted February 17, 2014 Share Posted February 17, 2014 Stool osmotic gap. Link to comment Share on other sites More sharing options...
Guest Paula Posted February 17, 2014 Share Posted February 17, 2014 She is not high socioeconomic status. Unemployed. Very disordered social history. I will suggest to the MD to travel down the path of psychogenic illness. I screened her for eating disorder when I initially saw her and everything was no, no , no and no to any such questioning. If I recall right, that is what made her cry. I think she is now psychologically dependent on the physician and is a reason why she is in the clinic so often. It will be interesting what he decides to do. I will peek at her chart and review the labs and consults so far. I find it curiouser and curiouser as time goes on with this woman. There are times I get an idea in my head and have blinders on and I have pigeon-holed her already as a psych patient. So my differential ability thinking skills have gone to pot. Not real pot as in THC, but in the toilet. Link to comment Share on other sites More sharing options...
whoRyou Posted February 17, 2014 Share Posted February 17, 2014 Paula: Having a degree in psych, you have definitely piqued my interest too. Please keep me posted. Link to comment Share on other sites More sharing options...
whoRyou Posted February 17, 2014 Share Posted February 17, 2014 Stool osmotic gap. Speaking of congenital diarrhea disorders Link to comment Share on other sites More sharing options...
cinntsp Posted February 17, 2014 Share Posted February 17, 2014 Stool osmolality/osmotic gap + testing for the laxative actives in the stool could be helpful. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted February 17, 2014 Administrator Share Posted February 17, 2014 Definitely sounds like a personality disorder from the way you describe her interactions with the physician. Link to comment Share on other sites More sharing options...
myironlung Posted February 17, 2014 Share Posted February 17, 2014 just out of sheer curiousity, has she been locked up before? Link to comment Share on other sites More sharing options...
winterallsummer Posted February 17, 2014 Share Posted February 17, 2014 As others have mentioned, stool osmolality and testing for substances may help answer your question. The underlying question here, though, is what are you going to do with the information? If extensive testing have already ruled out IBD, malignancy, celiac sprue, etc etc, is this information to give you peace of mind that there is not some rare organic d/o going on, or is it to confront her? If the latter, what would be your game plan? If there is an underlying psychological issue, that needs to be addressed, probably in a more delicate manner. If she is becoming detrimentally somatic, the best course of action may be to set up timed (but less frequent) office visits and work on strengthening a better client-provider relationship. Just my humble opinion. Link to comment Share on other sites More sharing options...
Moderator ventana Posted February 17, 2014 Moderator Share Posted February 17, 2014 psych consult see what they say if she does not comply with psych eval ask her to find a new PCP Link to comment Share on other sites More sharing options...
Guest Paula Posted February 17, 2014 Share Posted February 17, 2014 ^^^^^ to the above posters: I do not recall if she had any jail time. It is possible as most of my patients have at least been in the local jail at some point in their life. The point of finding out is to guide her in appropriate care. She has already had a referral to our in-house behavioral health counselor. Has not gone. I do confront my patients in a delicate manner. That is why most of the women end up crying. I think it is because it is the first time someone is asking the hard questions and counseling them about psych issues and getting counseling. I will run everyone's input here by the MD tomorrow when I see him. He will be the one to decide what to do. I'll let you know. We cannot discharge her. She is a tribal member and we are not allowed to except in extreme cases. (Such as a patient who threatens us with bodily harm.) Link to comment Share on other sites More sharing options...
Guest Paula Posted February 19, 2014 Share Posted February 19, 2014 I asked the Doc if he thought she might have factitious diarrhea. He didn't think so. GI consult was negative....she had EGD and colonoscopy. She's had stool studies for o&p, c;diff, etc. He did not order stool osmolality gap or Magnesium. He agrees she has mental health issues. He is sending her for consult for endocrinology because of abnormal thyroid tests. She's had several sets of TSH, FT4, T3...sometimes normal but one set of elevated FT4. I couldn't get my hands on her chart to read the notes. He is hoarding it in his office. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 19, 2014 Share Posted February 19, 2014 Does he actually know for a fact that she's having diarrhea (observed)? Had a pt. in house following an ACF who developed iliac crest graft site infection (NEVER happened on anyone else). Couldn't figure it out. Was caught putting stool in wound. He also played with plastic dinosaurs on his bedside tray (adult). No joke... Link to comment Share on other sites More sharing options...
Guest Paula Posted February 19, 2014 Share Posted February 19, 2014 No and trying to have an in-depth conversation with the doc is tricky. He's a nice guy but so high strung and ADHD that he loses interest in conversation in less than 60 secs. I will get the chart as soon as it gets put back on the shelf and review it. Her case has peaked my interest but if I solve it I need to make sure he thinks it was his idea. You get my drift!!!! Link to comment Share on other sites More sharing options...
db_pavnp Posted February 19, 2014 Share Posted February 19, 2014 Does he actually know for a fact that she's having diarrhea (observed)? Depends on your definition of "observed," but between the c.dif and o&p collections someone should have noticed the consistency. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 19, 2014 Share Posted February 19, 2014 Not necessarily, if dropped off in a sealed container at an outside lab, or even in the office. Link to comment Share on other sites More sharing options...
whoRyou Posted February 19, 2014 Share Posted February 19, 2014 Notice it's written by a MD Link to comment Share on other sites More sharing options...
patachok Posted February 23, 2014 Share Posted February 23, 2014 I am just a PAS-1, but as somebody mentioned IBS is likely. Very interesting, though! Link to comment Share on other sites More sharing options...
Guest Paula Posted February 23, 2014 Share Posted February 23, 2014 I still haven't been able to see the chart. I asked the lab tech if he observes the stool samples and he said no. It comes back to him in the sealed containers and he packages it for pick-up by our outside lab. Link to comment Share on other sites More sharing options...
Joelseff Posted February 23, 2014 Share Posted February 23, 2014 You can scope her looking for melanosis coli suggesting cathartic laxative use....I dont know if anyone already posted this...too lazy to read a the suggestions lol. Sent by my Samsung S4 Active via Tapatalk Link to comment Share on other sites More sharing options...
Guest Paula Posted February 23, 2014 Share Posted February 23, 2014 She had a colonoscopy and EGD, both normal. Link to comment Share on other sites More sharing options...
Joelseff Posted February 23, 2014 Share Posted February 23, 2014 She had a colonoscopy and EGD, both normal. Did the GI note a melanotic colon? Its considered a NL finding but sometimes won't be noted in the report unless looking for it. (I used to work GI and saw it all the time but only reported if it was a concern) if it wasnt present, she probably does mot use laxatives. Did you get the GI path back NL also? Sent by my Samsung S4 Active via Tapatalk Link to comment Share on other sites More sharing options...
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