jmj11 Posted June 20, 2013 Share Posted June 20, 2013 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. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted June 20, 2013 Moderator Share Posted June 20, 2013 multiple plastic inserts to reshape her face and forehead to be more "cosmetically appealing"? Link to comment Share on other sites More sharing options...
Moderator ventana Posted June 21, 2013 Moderator Share Posted June 21, 2013 no MRI images seen? my guess - huge hole in the septum..... Link to comment Share on other sites More sharing options...
Walkoffshot Posted June 21, 2013 Share Posted June 21, 2013 Osteoma. Either causing increased intracranial pressure, or entrapment of occipital nerve. Brain will be entirely normal. Your pessimistic that you can help her because your not a surgeon, but your can refer her :).. it is a riddle after all. Link to comment Share on other sites More sharing options...
benm93 Posted June 21, 2013 Share Posted June 21, 2013 maybe hormone related... you cant help her, but her hormones leveling off at menopause will. Link to comment Share on other sites More sharing options...
stellahead Posted June 21, 2013 Share Posted June 21, 2013 Inoperable cholesteatoma? Link to comment Share on other sites More sharing options...
jmj11 Posted June 21, 2013 Author Share Posted June 21, 2013 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 Link to comment Share on other sites More sharing options...
MedicinePower Posted June 21, 2013 Share Posted June 21, 2013 subscribing Link to comment Share on other sites More sharing options...
tigerlily Posted June 21, 2013 Share Posted June 21, 2013 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?? Link to comment Share on other sites More sharing options...
jdenning Posted June 21, 2013 Share Posted June 21, 2013 I'm curious about her presentation - in addition to the severe headaches she probably has some bizarre visual field defect and is dragging her leg. And she will say over and over "I just know there's something wrong." Oh, and she can't work. Link to comment Share on other sites More sharing options...
jmj11 Posted June 21, 2013 Author Share Posted June 21, 2013 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. Link to comment Share on other sites More sharing options...
tigerlily Posted June 21, 2013 Share Posted June 21, 2013 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. Link to comment Share on other sites More sharing options...
jmj11 Posted June 21, 2013 Author Share Posted June 21, 2013 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. Link to comment Share on other sites More sharing options...
Andreasmo Posted June 21, 2013 Share Posted June 21, 2013 Oh my goodness.. Have to wonder what could go through a persons head to make them think that would be ok. Link to comment Share on other sites More sharing options...
primadonna22274 Posted June 21, 2013 Share Posted June 21, 2013 Definitely somatization disorder. Send her to Contrarian :) Good luck Mike...these cases are always sad. Link to comment Share on other sites More sharing options...
jsfelder0417 Posted June 21, 2013 Share Posted June 21, 2013 Somatization Disorder, and/or Munchausen by Proxy... Link to comment Share on other sites More sharing options...
SocialMedicine Posted June 21, 2013 Share Posted June 21, 2013 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. Link to comment Share on other sites More sharing options...
whoRyou Posted June 22, 2013 Share Posted June 22, 2013 Somatization Disorder, and/or Munchausen by Proxy... My psychology degree is good for something or so I believe and if I had to guess I would concur with jsfelder Link to comment Share on other sites More sharing options...
TheCount Posted June 24, 2013 Share Posted June 24, 2013 Oh my goodness.. Have to wonder what could go through a persons head to make them think that would be ok. Agreed. This case is an odd one. Link to comment Share on other sites More sharing options...
tigerlily Posted June 24, 2013 Share Posted June 24, 2013 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. Link to comment Share on other sites More sharing options...
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