WILTIMS #494: Lies, LIES!

We had an interesting case today where a patient had certain symptoms but was probably lying about or at least embellishing his/her symptoms. The amazing part was that my attending called it after listening to me present the patient for about 30 seconds. I was shocked, because I had totally believed the patient and this doctor hadn't even seen him! What I had described as the patient's story just didn't make sense from a physiologic perspective. I tried to withhold judgement until the attending actually saw the patient. Once he did, it only took a few insider-knowledge tricks and almost immediately he had secretly exposed to the resident and I that the patient was lying.

One of the tell-tale signs was simply biological. People with a brain injury usually display slow eye movements. Normal people's eyes (and this patient's) dart around as they think. It's actually nearly impossible to smoothly move your eyes voluntarily if you aren't tracking an object. Try it! Keeping your head still, follow your own finger as you slowly point from left to right and back. Now try to do that same smooth eye movement without a finger to follow. It's really easy to see when someone else tries this in front of you, but you should still be able to feel that you're eyes are jerking across the path.

This other trick was not biological, but psychological. The patient answered several questions wrong, but always nearly right. If someone does this enough times it shows that they must know the right answer and are trying to be just the right amount of wrong. When people really don't know it's random and sometimes they're right, sometimes they're close, and sometimes they're totally wrong.

TIL: Vasculitides (autoimmune inflammatory diseases of blood vessels) that affect the brain are very often associated with headaches. But the brain has no pain sensation, so what is actually hurting? Well, while the fat and nerves of the brain itself don't feel pain, but the large blood vessels of the brain do and that's what is damaged in these diseases. Specifically, the arteries feel pain up to about an inch out from the Circle of Willis and the veins feel pain when they are of a similar size to the arteries, though the anatomic locations are harder to describe.

There are two modifiable predisposing factors for multiple sclerosis: smoking and vitamin D deficiency.