Reference no: EM133275260

Question: Jacob limped into the waiting room of the hospital holding his middle. He was directed to a nurse. "Upper left quadrant pain," said Jacob without much emotion. "I hope it's not a spontaneous splenic lac."

"Do you work in health care?" the nurse asked since non-medical professionals typically do not describe their abdominal pain by anatomical region nor do they use the medical term to describe a lacerated spleen.

"No," said Jacob with a deep sigh. "I just have bad luck."

Jacob was taken to a treatment room. Blood was drawn, and a technician came into the room to start an IV. Looking at his arms, the technician scowled. There did not seem to be any good places to insert the needle. "I am a tough stick," said Jacob, "so it's ok if you have to put the IV in my groin or neck." Jacob seemed to relax after the IV was started in his neck. "Ah, good old EJ," said Jacob. The technician found it odd that Jacob would use a medical abbreviation for "external jugular vein" and be comforted by the thought that he had an IV in his neck.

When the doctor came in, the thing she first noticed about Jacob was significant scar tissue across his abdomen. When she asked him about it, Jacob told an incredible story. He said that he had been working in Oklahoma installing satellite dishes when he had been caught outside in a storm. He was running from his truck to a storm shelter when he veered to grab a dog. He was on his way into the shelter with the dog when a tree branch was driven into his belly. Multiple follow-up surgeries over the course of several years were necessary to correct problems that had occurred, causing the heavy scarring that crisscrossed his midsection. "Gridiron gut," said Jacob.

The doctor examined Jacob and noted that he had pain and tenderness predominantly on the left side of his abdomen. She had heard of spontaneous splenic lacerations like the one to which Jacob referred, but had never seen someone who actually had the malady. There was nothing obvious in his blood work that helped diagnose his pain. He did not have a fever. The doctor feared that he might be having another issue from the tree branch incident and ordered a CT scan of Jacob's belly. "With contrast and barium swallow?" asked Jacob, acting a little too excited. Most people find the procedure uncomfortable due to the quantity of IV contrast that has to be ingested so that the internal organs are highlighted on the scan.

Within hours, the cause of Jacob's abdominal pain was clear: he had a dozen foreign objects in his stomach! Jacob readily admitted that these objects were eight disposable razor blades encased in plastic and four AAA batteries. When the emergency room doctor confronted Jacob with this finding, he shrugged and asked, "How does my spleen look?" The doctor conferred with a surgeon about what to do about the items in Jacob's stomach. While not immediately life threatening, if a razor blade perforated internal organs, Jacob could bleed to death. There was also some concern about the caustic acid in the battery doing internal damage, too. If Jacob required surgery, it would be difficult due to the excessive scarring across his abdomen. The decision was made to use a device called an endoscope to remove the objects from Jacob's stomach through his mouth. The endoscope has a small camera with some surgical instruments attached to the end to locate the objects in the stomach, grab them, and pull them out.

The surgeon explained that he was going to use sedating medicine to make Jacob drowsy and unaware of the procedure. "Fentanyl and Versed cocktail?" asked Jacob. The surgeon nodded, wondering how a non-medical professional knew what would be used.

It took nearly three hours to extract the razor blades and batteries from Jacob's stomach. The surgeon decided to admit Jacob to the hospital to monitor for any post-operative complications. The night was uneventful, but Jacob was not feeling any better. Some belly pain was expected, but his pain was much worse than the typical case. A repeat CT scan of his abdomen showed four more razor blades. "Hmm," said Jacob, "I guessed they missed them the first time around." A visibly perturbed surgeon returned to the hospital to repeat the procedure of the night before. This time, a post-procedure scan was completed to verify that he had no more foreign objects in his stomach. Jacob returned to his hospital room; this time with an aide to sit with him and make sure he did not try to eat things that were not food.

The aide later asked Jacob's nurse, "Why would he do that to himself?" The nurse was at a loss for words. While this behavior was harmful, there did not seem to be any suicidal intent on Jacob's part. Jacob defended the fact that he had not told the doctors what he had done by saying, "I have done it before, and it has never caused any problems. It did not occur to me that it might be the source of my stomach pain."

Sometimes drug addicts will go to great lengths to get narcotic pain relievers. This did not seem to be the case with Jacob, as he was not asking for pain medicine. Could he be doing this to get free meals and a place to stay? Many people who work in hospitals have seen people fake an illness for "three hots and a cot," but this behavior was extreme. When doctors discussed discharging him from the hospital, they discovered that Jacob had a fever, his arm was infected, and there was blood in his urine.

A psychologist came to see Jacob. Sometimes people who eat non-food items are psychotic or intellectually disabled. Jacob was neither. He was very clear that he was not intending to hurt himself. "If my intent was to hurt myself, why would I have come to the hospital seeking help?" he asked. He said that he had had a "tough childhood" and developed some "maladaptive coping mechanisms," but insisted eating inedible objects was simply a quirky thing he did under stress. Jacob admitted to some problems with drugs and alcohol but attributed this to his "PTSD from being in that tornado." He denied ever being under the care of mental health professional. He said that he was drifting around the country on money that he received from a death benefit when his wife was killed in a car crash several years previously.

The psychologist's visit was interrupted by doctors from the infectious disease department. Jacob had a high fever, and the infection in his arm was getting worse. The infectious disease doctors were called in to figure out what was happening. They took samples from him and sent them to the lab.

After a few days, Jacob responded well to the antibiotics that were administered intravenously to fight off the infection. The mystery of why there was blood in his urine was not solved, but the problem had not recurred. Jacob had not swallowed any foreign objects and was not giving the hospital staff any trouble. His fever was resolving and there was once again the talk of discharging him from the hospital. The blood culture results had come back. Jacob was suffering from an infection caused by an oceanic organism rarely seen in the inland city where the hospital was located. But in the waiting area of the hospital, there was a sizeable saltwater fish tank.

Medical records released from a previous hospital and surveillance video from the hospital's security's cameras led the psychologist to diagnose Jacob as suffering from ______ disorder. Jacob had worked as a nursing assistant and had some rudimentary understanding of medicine. He was known to travel from one hospital to the next and had over two dozen abdominal surgeries. It was unknown if he truly had been in a tornado. When security footage was reviewed, Jacob was observed using a small syringe to take water out of the saltwater aquarium and inject it into his IV.

When Jacob was confronted about his behavior, he became indignant about the "unprofessional behavior" of the hospital staff. He demanded to leave and, since his medical condition had improved, was permitted to do so.

Question 1. What disorder do you think characterizes Jacob?

Question 2. For each criterion, either paste in indicative quote(s) and/or explain with specific evidence why that particular point is met for the diagnosis. Please include as many symptomatic quotes or as much evidence as you can find

Question 3 what treatment(s) you would provide for Jacob, what that treatment would involve, and why this treatment would be useful.