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Programme for tonight

• Brief interventions for alcohol - Angus

Henderson

• Pain pathway - Paula Wilkinson

• Getting the right patient in the right place –

the GP role in Munchausen

• Chronic Pain and Vitamin D

– Subhodha Thanthulage

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I want to tell you a story

John Guy

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Munchausen syndrome

Baron Munchausen 1720 – 1797

Teller of tall tales•Riding cannon balls•Riding to the moon•Pulling himself out of swamp with his own hair

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Types of behaviour

• Pretending to have psychological symptoms: for example, claiming to hear voices or claiming to see things that are not really there.

• Pretending to have physical symptoms: for example, claiming to have chest pain or stomach ache.

• Actively seeking to make themselves ill: such as deliberately infecting a wound by rubbing dirt into it.

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How common?

• 10 of 1300 patients in Canadian hospital study

• May be more as patients often succeed in deceiving medical staff

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Tracey

• Born 1981• 30 weeks 1.96kg (37 wks

Dubowitz)• Parents married shortly after • (2 step sisters from mother’s first

marriage)

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• 1983 discharged from paeds follow up

• 1989 tonsillectomy

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1994

• Withdrawn - referred for paeds opinion• Missing a lot of school c/o severe

headaches– CT scan normal

• Breathing problems ?asthma – Responded to pulmicort

• Eating a concern• ?needs referral to Child Psych• Dermatitis artefacta

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1995

• Paracetamol overdose - saw CFCS once

• (Step sister divorced - 6 children)

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1997

• 6.1 Pelvic USS normal (1st)• 19.5. Emergency admission abdo

pain - USS normal (2nd); Treated for PID

• 29.8 Seen by CFCS ‘finding it hard to be listened to regarding her worries

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11.9.97

• Emergency admission dysfunctional bleeding USS normal (3rd)

• Weight loss noted living on bag of crisps and Kit Kat

• Rx dietary supplements but worried re body image

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1998

• 29.1. Appendicectomy

• 14.7. Abdo pain USS normal (4th)

• 15.10. VVs ligated

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1999

• Anorexia nervosa• 15.1 Abdo pain PV bleeding USS normal (5th)• 2.6 Overdose 9 tablets Mefenamic

acid in Skegness• Tale of man in Essex threatening to assault

her• 13.6 USS normal (6th)• 1.9 ‘raped’ under death threat over

9m in Skegness owner of karaoke bar• Back injury

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2000

• 15.3 Satisfies incapacity test• 31.3 GI endoscopy normal• 27.7 USS abdo normal (7th)• 28.7 Overdose admitted to Linden Centre

– 20 units alcohol per day– 3 sisters (went up to 4 sisters by December)

• 9.11 Lumbar spine Xray normal (1st)• 21.12 Married

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2001

• 19.1 Overdose seroxat• 10.04 Sought annulment• 18.9 Shanie born 2.71kg• 28.11 Lumbar spine Xray

normal (2)

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2002

• 19.2USS normal (8th)• 1.4 Breast augmentation• 29.5Lumbar spine Xray normal (3)• 20.8 Lumbar spine Xray normal

(4) (Radiologist - radiation equiv 260 CXRs)

• 4.10Admitted with back pain

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2002 (cont)

7.10 Told psychiatrist that pain specialist had said her back was broken in 3 places

18.10 Admitted with retention of urine under orthopaedics (MRI scan T11 to L3 normal)

10.11 Admitted under orthopods with back pain Xray lumbar spine normal (5)

14.11 Acute retention of urine under vascular team

16.12 Seen in OPD mobilising with crutches

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2003/4

• 03.03 Smoke inhalation house fire• 06.03 Catheter inserted for acute

retention• 02.04 says was told has

emphysema - histrionic when chest assessed

– CXR normal

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2006

• 12.04 Mother died aged 59 bronchopneumonia

• 01.06 DSH• 20.07 USS normal (9th)• 01.08 DSH• 20.09 Facet joint injection• Bankruptcy proceedings • 01.11 infective exacerbation of

asthma

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2007

• 9.03 DSH• 1.05 TMJ pain• 18.06 self harm hit hand• Dermatitis artefacta• 20.11 Baby Kelsey born

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2008

• 13.02 Mirena inserted• 01.03 OOH Heavy vaginal bleeding

post coil fit Seen by Gynae - ward attender • 11.05 OOH Painful abdo lump today

Rx Doxycycline

• 11.06 USS pelvis Normal (10th)• 11.07 120mg Depo-med and 5ml LA

to abdo wall

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2008 (ct)

• 10.09 Right radio frequency lesioning L3 L4 L5 and S1

• 15.09 Laparoscopic right and left ovarian cystectomy Inconclusive histology

• 4.11Flexible sigmoidoscopy benign polyp removed

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2008 again

• 5.11USS pelvis (11th)• 11.11 Pain clinic Butrans 10

and TENS machine• 3.12Flexible sigmoidoscopy

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2009

• 18.03 USS pelvis normal (12th)• 30.03 Psychiatrist concerned

re prescriptions of opiates• 01.05 GP concerned re

increasing doses of morphine from pain clinic

• 10.06 Joined our list

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2009

• 14.06 Admitted via OOH headaches and scalp lumps – dermatitis artefacta

• 02.07 Our concern re morphine prescription – noted partner does not work as is full time carer – Secondary gain +++

• 16.07 Noted low threshold for pain

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2009 (ct)• 13.08 Pain clinic – small dose

of morphine don’t worry – will benefit from relaxation and hypnotherapy

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Since joined our list

• Have talked to each other about the problem – whole team is aware

• Tried to offer continuity• 66 appointments with us to date

– 26 with main doctor– 27 with LG, JG and JM

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Notes arrived

• 4 large envelopes• Summarised• Written to

– Psychiatry– A & E– Gynae– Pain Clinic– OOH

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Response

• Very positive from psychiatry• Only 3 OOH attendances – mostly

just recently so need to reinforce• Pain clinic continue to give caudal

epidurals 3 so far – notes were missing from main folder when seen

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Talked to patient

• Explained that there was no evidence of her ever having broken her back

• We need to try to avoid harming her with potentially dangerous interventions

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Remains a challenge

We have added13th and 14th pelvic USS3 lots of TFTs, Chemistry, FBC and ESR2 CRP1 HVS / Chlamydia 1 Stool

ALL NORMAL1 Vitamin D level

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Importance of GP role

Only holder of most of the information – no one else can see the overview

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