by Jarrod Shapiro, DPM Joined practice July 2006 of John K. Throckmorton, DPM Lansing, Michigan

Patients May Lie, But the Body Tells The Truth Much of our medical decision-making depends on relying on the truth of what our patients tell us. The visual analog scale for pain is just such a subjective test. We all know, though, that our patients often tell us selected parts of the truth. I’ll bet there are few physicians alive today who’ve never had a patient overestimate their pain level for more narcotics. We may experience this deficiency of truth among our patients, but we also know the body doesn’t lie.

Recently, I had a new non-diabetic patient complaining of bilateral paresthesias and diffuse foot pain. After obtaining his history, in which he related some alcohol use in the past but none currently, I examined him, having already noted his large, erythematous nose with dilated blood vessels (rhinophyma).  The rest of his exam continued to reveal neurologic discrepancies, such as diminished tandem walking, loss of sharp touch in a stocking distribution, and a positive rhomberg with his eyes closed.  All are signs of a distal symmetric polyneuropathy.  His verbal history and exam just did not seem to match. 

I subsequently ordered labs, which were all normal except for his toxicology screen, showing an elevated ETOH level.  He later admitted to a higher and more current use of alcohol than he had originally described.

Now I’ve been taught, as most of you have, that the diagnosis can be made by the history alone in 90-95% of cases, and I believe that’s true.  I still make every attempt to diagnose my patients before examining them and definitely before ordering specific tests.  However, I have found myself increasingly relying on the physical examination as the more “believable” information.  For example, if a patient tells me her plantar fasciitis pain is 10/10 but she’s sitting in the exam chair with no signs of distress and doesn’t withdraw when I palpate the area, then I won’t believe her pain is as severe as she states.  On the other hand, I’ve had patients who try to deny their pain, yet are clearly painful.

Let’s take another example we’ll all relate to: the diabetic plantar neuropathic ulcer.  All of my patients 100% of the time comply absolutely with my nonweightbearing instructions.  They all leave their offweighting device on 100% of the time, and they never sleep without them.  Do you believe me?  If you do then I have some swamp land to sell you.  I know they’re lying when their dressing is removed, and I can see the hyperkeratotic ulcer rim.  It doesn’t happen if they’re not walking on it.  Noncompliance is the rule, not the exception. 

This new doc, for one, listens to what his patients have to say but takes much of it with a grain of salt.  As a general rule, if the physical exam does not match what the patient says, part of the picture is hidden.  Like a detective, put the whole picture together before making a judgment, and remember, patients may lie but the body tells the truth.

Jarrod Shapiro, DPM
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