Q: I've got a pt., 45 y.o. male, came to me 7/24/01 with acute onset of paresthesias and slight "weakness" (of which there was no evidence using dynamometer) in left grip. We have resolved MOST of that complaint. 8/21 he developed a cough which persisted until recently through 2 courses of antibiotics and a steroid inhaler. 8/28 he developed a "burning pain" in the left intercostal 5/6, tender to palp, with no etiology. 9/4 stated pretty much no problem. 9/7 tr pt in left pec worse.. 9/28 he develops a stated terribly painful tr pt at inf. angle of left scapula. Today, he states he experienced vertigo at approx. 10:30 a.m. yesterday which persisted thru the day--his scapular tr pt is also severely bothering him. He states pain upon palp of ALL thoracic SPs and upon palp of left scap area. BP fine, Rondbergs fine, seated cervical rotation test fine, hyperventilation test neg., x-rays neg for rib fx, chest films neg for pathology... Here's my concern: his list of complaints changes and/or lengthens constantly. He is chronically depressed, anxious and angry (I've know him for yrs) and complains about that regularly, stating he "should do something" about it, but never has. He works a LOT, fairly physical work in catering, butlering and extra work on TV. He's of short stature and sleight of build, I don't think he's had a female in over a decade...is there some insidious medical problem here or is it a psych issue? He always "requires" extra time in the office with his mysterious ailments...I'm at wits end. Any thoughts? A: Thanks for your e-mail. You'll run into a number if like cases throughout your career .. whether a DC or MD. There are two issues here. First .. this person needs extra attention and gets it with his chronic and new conditions. People listen and have compassion .. this is what he craves. Second .. his problems may be visceral and therefore "real or not" it opens you up to risk management if you do not dilute your responsibility with a medical backup. Obviously .. you are documenting his subjective complaints .. have you discussed a referral to his primary physician or a medical specialist .. even if he is not interested .. have you written it in your notes or mentioned it in writing (with dates) a number of times in your files .. just a few entries of "I recommended he seek a medical referral for a complete work up .. I will assist with a referral if he wishes." This short note possibly protects you from any potential malpractice with non referral actions. If you have names of some MD's to recommend even the better. I hate to add this but even the best of friends who you know for years can be influenced and later come back to bite you in the butt when their perceived or real conditions do not respond to your care and possibly worsens. Now .. if this was my patient .. I would be conservative with care .. listen as compassionately as I can .. provide and document conservative lifestyle advice (document as well) such as exercises .. weight loss .. meditation .. spiritual guidance via their church .. etc. If you are frustrated with his response to care and continued symptoms and psychological residuals .. mention a few referrals and advice and hope for the best. If you wish to release him .. mention that his complaints need further attention and possibly another chiropractic technique would work and therefore a DC referral or medical. Other than that .. we all have our share of frustrated patients .. many who we really would love to help but we only get so far .. hang in there .. try a few new chiropractic techniques and always "cover your ass." Have a Great Day Dr. M http://www.chirosmart.net