What Do You Do for the Man Who Has Everything?

I mean every symptom.

"My chest and throat feel like there are hot needles stabbing them, and my left side feels heavier than my right. I think something is seriously wrong with my body. And nobody will tell me what's wrong."

The guy sitting in front of me is wired. He's anxious and seems scared. It's obvious he's been through some hard times. Many years ill-spent, many drugs taken, and no doubt many bridges burned, torched, scorched. The crimes he's committed have finally caught up with him, and he's landed in prison for who knows how long. Now he's found this not-yet-cynical PA student who's listening attentively, and he unloads.

"I had this car accident when I was 24, and they gave me a shot in my spine. Do you think they might have messed me up? I mean that was like 20 years ago." He looks at me, and I realize I can no longer just nod my head in respectful listener mode. He expects an answer.

"Your symptoms don't sound like that's the case," I say. "You'd likely have some lower extremity problems, versus left arm problems." He's OK with that answer. Whew.

"I don't want to be around anyone," he explains. "I just stay in my cell as much as possible, because I don't know what I might do to somebody." Uh oh. I wonder if I should be worried for my safety, and I start to regret shutting the door for privacy at the beginning of this encounter.

"I can't stand the people here. I hate the fake gangsters. They ain't shit. I was in Oakland where they had real gangsters. This one white dude bought a pack of cigarettes off a black guy, and the skinheads told him he had to go back and make it right, meaning he had to do something to that black guy. When he didn't do it, they stabbed him 11 times. Right in front of me."

I think to myself maybe fake gangsters aren't so bad, and I say something along those lines to him. He actually agrees, and then continues with a litany of complaints that has my head spinning. Sometimes he's short of breath. It can happen when he's walking or just sitting. Sometimes it happens late at night. Sometimes he feels like he's "checked out" and he feels apart from himself. At those times he can't move or speak. He's also tired all the time. His face feels flushed. He gets dizzy and light-headed. His brother died of cancer in his forties. He's 44 and thinks he's next.

I decide to examine him. All pretty normal, despite the fact that he looks much older than he actually is.

Physical Exam...
Vital Signs: BP 126/84, HR 75, 97% on RA.
General: Well-developed/Well-nourished. Visibly anxious.
HEENT: Normal shaped head, no signs of trauma. No pallor to conjunctiva.
Lungs: Clear to auscultation bilaterally. No ronchi, rales, wheezes
Cardio: Regular rate and rhythm, no Murmurs/Rubs/Gallops
MS/Ext: No weakness in upper or lower extremities.
Neuro: Extra-ocular muscles intact. No focal neurological symptoms.
Lymph: No lymphadenopathy.

I've glanced at his medical history and he's been through every test there is. EKG, Cardiac Angiogram, EEG, lab test after lab test. With the exception of Hep C with a very low viral load, they're all normal.

I also see that he's bipolar and antisocial, with a Global Assessment of Functioning (GAF) of 51 to 60. This means "Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) and/or Moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with co-workers)."

I ask him about medications. In the past he's taken Gabapentin, Topiramate, Meclizine, and a few others, but nothing currently. His religious views make him reluctant to take any medicines. We talk a little about seizures, which he had as a child, and I explain that some of his symptoms may be connected to that. He's very glad to hear that, and seems grateful that I'm listening and thinking about what might be going on with him. Then I cautiously ask him if he's visited with the facility's psychologist, who I have heard is doing some sort of biofeedback therapy with inmates and getting good results. I wait for an angry response, for him to say I think he's just crazy.

Instead he says, "I'm not into self-hypnosis, I'm a Christian." Hmmm. In another time and place, that comment would be met by a smart-aleck remark. Today, I don't dare.

Instead, I re-frame it to him. "Have you ever had a time where you talked to yourself, and helped yourself get through a tough moment?" He likes that analogy, and says he's talked himself down from many bad moments.

We finish up by going through each of his recent lab tests, line-by-line. I tell him where I would look if I was worried about specific problems, and he starts to feel better as we progress through the litany of normal results. I don't think anyone has ever done this for him before. He doesn't say it, but I can feel he no longer thinks he's going to drop dead.

I suggest he make an appointment to see the psychologist and give the relaxation/biofeedback thing a try. I also say that if he thinks he's having seizures or any other serious problem, he should come back to the clinic right away. He says he will do that. He also promises to see the psychologist. He shakes my hand and we walk out to the front door together.

Did I help this guy? I think so. Did I miss some huge medical emergency that is going to kill him. Could be, but probably not. He's had these symptoms forever, and smarter folks than me have had their shot at diagnosing him. All I did was listen to him, lay my hands on him a little, and decipher some lab tests for him. Whatever I did, it worked, and he walked out better than he came in.

I'd say that's pretty good medicine.