Portal de Periódicos da CAPES

Phantom Leg Edema

2010; Elsevier BV; Volume: 56; Issue: 5 Linguagem: Inglês

10.1016/j.annemergmed.2010.02.001

1097-6760

Leana S. Wen,

Venous Thromboembolism Diagnosis and Management

[Ann Emerg Med. 2010;56:580-581.] Midnight. The triage nurse rolled her eyes before handing me the chart for bay 9. “Charles Kruger, also known as Crazy Charlie,” she told me. “Everyone knows him. He always comes in for the same thing. Nothing different today. He never lets us take off his clothing or do anything but look at his legs.” The chief complaint on the intake sheet was “leg edema”; someone had put the word “phantom” in front of it. I glanced over at the bay. The curtains were partially drawn, but I could see a 40-something gentleman sitting on the bed, who appeared to be impeccably dressed in a pinstripe suit. He was using a lint brush and looking at himself with a pocket mirror. Vain, maybe, but crazy? I walked to the room and knocked on the door. “Mr. Kruger, hello. I'm Dr. Wen.” “That's Charlie to you, doctor. How do you do?” Charlie had a distinctive South African accent. When I asked Charlie where in South Africa he was from, he was delighted. He told me that he was from Durban, grew up there then lived in Johannesburg for college then work. He moved to Boston just 2 years ago when he got divorced and his company needed an engineer on a project here. He liked the change of scenery but missed his boervors and biltong. When I told him that I knew SA well and that my significant other is also a South African engineer, he grabbed my hand and shook it enthusiastically. “Howzit, doctor!” He said, “Does he know lots of South Africans in the US?” I shook my head. “Then you two must come to the annual SA braai in New York City. It's in June. It's a grand event, simply super. You must come!” I smiled and said maybe. For now, what brought him here? Charlie's smile disappeared. “My legs, that's why I'm here.” He told me that his legs had been swollen “for a long time.” He had tried everything for to reduce the swelling, but nothing worked. He often had terrible leg pain. Today the pain was OK, but he came in because the swelling was much worse. “It's so terrible,” he bawled, tears streaming down his face. “Look at my legs!” His shoes were already off, and he took off his socks and rolled up both pants legs. His legs looked normal to me. I pressed on his feet, then his ankles, then his calves. “See!” he said triumphantly when I pinched his calves. “See how swollen it is! It is getting worse every day.” There was no edema. I excused myself and went to look at his medical records. The records documented what the triage nurse had said. In fact, for the last 6 months, Charlie came once a fortnight, always in the middle of the night. He always came in complaining of leg swelling, he always refused a full physical exam, and he just seemed to want his legs to be looked at. He had gotten x-rays and ultrasounds, never with any positive findings. There were multiple notes commenting that he left AMA, especially after he was told he could not have pain medications. In the ED we saw a lot of frequent fliers like Charlie who had “phantom” complaints. The implication seemed clear. But was it so clear? Charlie's story didn't fit with being a drug seeker. It didn't make sense. Maybe he was actually Crazy Charlie and made up his whole life, but too much of it sounded too real. And he wasn't asking for pain meds. He was there only for this continued phantom leg edema. Something was distressing him. I went to talk to him. “Charlie, I know you came in many times in the past for the leg swelling. I'm not sure I see any swelling, so I don't think I can really help you with that. Is there anything else I can help you with?” He shook his head. “That's what they always say.” He made a move to gather up his belongings. I saw that his key ring had a cricket ball on it. “I was at Newlands last year,” I told him. “Five days of test match cricket, SA versus Australia.” He smiled. “That's something, eh? Wish I were there.” “Maybe next time, 4 years' time, right?” I replied. He got very quiet. I walked over to his bed and took his coat and belongings from him and placed it in on the chair. He sat down on the stretcher. I sat down next to him and took his hand. “Now will you tell me what's going on?” Little by little he told me. For the last 6 months, he had been having more trouble with his bowel movements. He was frequently constipated. There would often be blood and mucus but no stool. When it did come out, his stools were pencil thin. He frequently had abdominal pain. I asked him what he thought was going on. “Cancer,” he told me quietly. “That's what I think is going on.” I told him that I would have to do a full exam on him. Without a word, he got undressed. The exam revealed minimal bowel sounds and a palpable mass in his rectum. He agreed to a CT to see if he was acutely obstructed. It showed that he was not, but that he had a large rectal mass and heterogeneous spots in the liver. Charlie took the results in stride. It's what he had feared for months but could not say. He didn't want to stay overnight at the hospital but promised to go to the oncology clinic the next morning. I wished him good luck. “Maybe I'll see you at that NYC braai?” “Maybe,” he said. I saw Charlie again, some months later, in the ED. This time the nursing intake sheet read “nausea and vomiting.” He had undergone surgery and now had a colostomy bag. He just started chemo and radiation and had come in for dehydration. Review of systems was otherwise negative. No more phantom leg swelling. “How are you doing, Mr. Kruger?” I asked him. “That's Charlie to you, Doctor. Howzit?” Before I could ask him whether he remembered me, Charlie lit up in a grin. “Did you ever make it out to the annual SA braai in New York City? It's in June. It's a grand event, simply super. You must come!” “You know what, Charlie,” I said, grasping his hand. “This year, I just might do that.”