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Case Riddle


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This is one of my case riddles . . . simple . . . with one or two guesses.

 

So, yesterday I saw a new patient. She is a 42 year old female with a long history of severe headaches. She has no other underlying chronic illnesses Dxs but a generally positive ROS. The ER had "ordered an MRI for this visit before referring me."

 

I clicked on the radiology reports to see the brain MRI and what did I see that makes me very pessimistic that I can help her . . . ever? I will give you a hint, her brain was entirely normal.

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Of course all of those are reasonable guesses. Let me add . . . she had a new record . . . 172 radiological studies in the past 4 years. She also has no major chronic underlying illnesses (MS, RA, COPD, CAD, DM). She was recently hospitalized for FUO and probably sepsis. She was admitted a few months ago for intractable abdominal pain. She has unexplained repetitive pyelonephritis (last year). Her husband is a Medic and has notebooks filled with typed information about her bodily functions, meds, sleep patterns, and all markers of human life. Hmmmmmm

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Of course all of those are reasonable guesses. Let me add . . . she had a new record . . . 172 radiological studies in the past 4 years. She also has no major chronic underlying illnesses (MS, RA, COPD, CAD, DM). She was recently hospitalized for FUO and probably sepsis. She was admitted a few months ago for intractable abdominal pain. She has unexplained repetitive pyelonephritis (last year). Her husband is a Medic and has notebooks filled with typed information about her bodily functions, meds, sleep patterns, and all markers of human life. Hmmmmmm

 

 

Oh noooo, Münchausen syndrome??

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You know, I'm curious about Münchausen syndrome or, if her husband is involved, by proxy. Right now I would call it somatization disorder at least. But my heart sank when I saw her radiology file. The previous record was a young girl with about 90 exams in about the same period of time. All of this is on the Medicaid dollar as well. But think about it. I've had some very sick patients (terminal metastatic breast cancer, AIDS, End-stage renal disease + COPD + IDDM +?? who would not have than many radiological exams in 4 years. Maybe you've seen that many exams that were done for legitimate disease. But when I see someone so deeply invested in being sick, there is no way I can led them to wellness.

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Agreed, and yes, it is sad. When you say Medic, I assume he is in the military, so all on Tricare's dollar? A question I would have is why have they ordered repeated imaging studies in absence of any clear clinical indication, even more so with her track record. Thanks for sharing JMJ.

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Agreed, and yes, it is sad. When you say Medic, I assume he is in the military, so all on Tricare's dollar? A question I would have is why have they ordered repeated imaging studies in absence of any clear clinical indication, even more so with her track record. Thanks for sharing JMJ.

 

My bad. I should have said EMT. I have no clue why she has had so many tests. There're four ERs in our local area and she visits all four on a regular basis. This is where I am suspicious about Münchausen is that she does have real findings at times, like with this last admission, of septicemia. But it is bizarre that a husband would have a three-ring binder with neatly typed documentation and spread sheets of his wife's vital signs (including BMs ) and etc going back for months of not years. There is more bizarre-ness to this that I can't put here because this is a public forum and it is a small world.

 

I will tell a story from about 17 years ago. I had a 28 year old female patient who had very strong somatization tendencies. The really strange thing was her relationship with her creepy boyfriend (think a little Charlie Manson here). He tracked her urine output, menstrual cycles, BMs and etc. They had this role-playing thing going on, which she said she strongly endorsed (I felt like she needed rescuing from this but she said that she was the instigator). He was her Master and she his willing slave (she explained it as a perpetual sexual game they played). But she got very sick and ended up in ICU when she became septic. The problem was, her boyfriend, who was a bike (as in bicycle) enthusiast required her to carry bike parts in her vagina. We are talking gears, chains and etc. Apparently her cervix was abraded and developed a nasty infection. They eventually did a hysterectomy in the hospital. I wish I had known Freud and I could have consulted with him. There are some similarities to this riddle case story that I won't go into here.

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A lot of tests are run because of liability concerns. What if this is the one time there is an appendicitis or aneurysm. Also, more than liability, sometimes running numerous tests on people is what is necessary to rule out something other than a mental health manifestation. A boy who cried wolf scenario would be a disaster and happens often. I always try and connect people with a skilled (not an easy task) psychologist or psychiatrist with the idea that they can help them manage these symptoms until we figure out the medical cause. Sometimes that can be a gateway to mental health care .. many times it is not.

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A lot of tests are run because of liability concerns. What if this is the one time there is an appendicitis or aneurysm. Also, more than liability, sometimes running numerous tests on people is what is necessary to rule out something other than a mental health manifestation. A boy who cried wolf scenario would be a disaster and happens often. I always try and connect people with a skilled (not an easy task) psychologist or psychiatrist with the idea that they can help them manage these symptoms until we figure out the medical cause. Sometimes that can be a gateway to mental health care .. many times it is not.

 

Ok, I see, I definitely understand that. I do like the idea of having psych helping out "while the medical cause" is figured out.

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