Tuesday, December 12, 2006

The Hysterical "Unconcious" Patient

This seems to be not an uncommon presentation. A factory worker brought in to the clinic by her co-workers claiming that she had fainted or "pengsan". Now "pengsan" can be very subjective, from just feeling dizzy to a true vaso vagal syncope. However lets assume that we have excluded all the major causes of syncope. The patient is young, has a stable BP, is not hypoglycaemic, has a normal heartbeat and is not on any medications.

Of course we don't want to be cruel or subject him/her to painful tests, but these are a few tests you can use (from the MMR forums) :

  • try holding her hand above her face/cheek, then suddenly let it drop.
    If she was faking, the hand will always avoid hitting the face.
    If the hand DOES fall alway from the face, you might even want to try "throwing" her hand into her cheek! It's amazing how the hand will avoid hitting the face!
    (Of course, do NOT try this if you suspect that the patient may have had a stroke or other problem which would have caused a flaccid paralysis!)
  • Anaesthetists also use the "finger brushing against the eyelashes" test to see if a patient is unconscious. An unsconscious person would not blink.
  • Another way to test if the patient is faking unsconsciousness, would be to hold open one or both eyelids, and then make sudden threatening gestures towards her face, but stopping just short of hitting her. A truly unsconscious person would not flinch.
  • Sternal rub with knuckles, pen on fingernail
  • Smelling salts
  • Murtagh describes the accommodation method where a mirror is held over the open eye. The pupil should constrict with accommodation from the patient looking at his or her own image.
Off all of them, probably the "let the hand fall towards the face" and "brushing the eyelashes" are the most humane. After all, there is normally a reason for the hysteria, either stress or psychological problems. We shouldn't berate the patient too much, but allow them some time, and an escape route to "wake up".


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