Clinical Geriatrics

Case Presentation
The patient, Ms. C, is a 68-year-old unmarried white woman who presents to the emergency room (ER) with complaints of shortness of breath. She is well known to the hospital staff due to her frequent visits and because she was employed as a nursing assistant there for more than 30 years. Ms. C is a long-time smoker who suffers from chronic obstructive pulmonary disease (COPD). In addition, she has a diagnosis of hypothyroidism and underwent a lumpectomy followed by radiation therapy for carcinoma of the right breast four years ago.

Ms. C is given a nebulizer treatment for her shortness of breath, but the ER physician finds that her lungs are clear, with no wheezing. A chest x-ray reveals a mildly enlarged heart. Ms. C is tachycardic in the ER, with a heart rate up to 130 beats per minute. Her blood pressure is low, reaching 76/48 mm Hg. She is admitted to the hospital due to concerns of a new cardiac problem and is placed on the telemetry unit.

Following admission, Ms. C develops a number of new complaints. She reports difficulty swallowing, neck pain that radiates to her shoulders, headaches with blurred vision, skin rashes, and difficulty walking. She is evaluated by physicians from a variety of specialties, including cardiology, pulmonology, otolaryngology, neurology, orthopedic surgery, dermatology, and endocrinology. She undergoes computerized tomography scans of her head, neck, chest, abdomen, and pelvis. Laboratory work-up is significant for an elevated thyroxine level with a low thyroid-stimulating hormone, and her dose of levothyroxine is reduced from 100 mcg daily to 50 mcg daily.

With each consultation and diagnostic test, Ms. C seems to have more complaints, including weakness and itching. Many of the consultants become frustrated with Ms. C, as her diagnostic tests do not find any significant abnormalities other than her chronic but stable COPD. She is often noted to be scratching her neck, chest, and arms so forcefully that her skin bleeds, but a skin biopsy performed by the dermatologist is normal. Concerns are raised that Ms. C is causing her problems or simply making up her symptoms.

She is transferred from the telemetry unit to a general medical floor, but insists on using oxygen via nasal cannula continuously, even though both the cardiology and pulmonary consultants have determined that she does not need this. Her primary care physician reports that he has always found Ms. C to be rather needy and to have many somatic complaints. However, he followed Ms. C during her cancer treatment and noted that she tolerated surgery, radiation, and a course of chemotherapy well. He also cared for Ms. C’s mother and recalls that she saw him frequently with many somatic complaints as well. He asks for a psychiatrist to examine Ms. C and hopes that he will be able to discharge her from the hospital fairly soon.