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Programme for tonight

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. I want to tell you a story. John Guy. Munchausen syndrome.

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Programme for tonight

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  1. 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

  2. I want to tell you a story John Guy

  3. 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

  4. 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.

  5. How common? • 10 of 1300 patients in Canadian hospital study • May be more as patients often succeed in deceiving medical staff

  6. Tracey • Born 1981 • 30 weeks 1.96kg (37 wks Dubowitz) • Parents married shortly after • (2 step sisters from mother’s first marriage)

  7. 1983 discharged from paeds follow up • 1989 tonsillectomy

  8. 1994 • Withdrawn - referred for paeds opinion • Missing a lot of school c/o severe headaches • CT scan normal • Breathing problems ?asthma • Responded to pulmicort • Eating a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

  9. 1995 • Paracetamol overdose - saw CFCS once • (Step sister divorced - 6 children)

  10. 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

  11. 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

  12. 1998 • 29.1. Appendicectomy • 14.7. Abdo pain USS normal (4th) • 15.10. VVs ligated

  13. 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

  14. 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

  15. 2001 • 19.1 Overdose seroxat • 10.04 Sought annulment • 18.9 Shanie born 2.71kg • 28.11 Lumbar spine Xray normal (2)

  16. 2002 • 19.2 USS normal (8th) • 1.4 Breast augmentation • 29.5 Lumbar spine Xray normal (3) • 20.8 Lumbar spine Xray normal (4) (Radiologist - radiation equiv 260 CXRs) • 4.10 Admitted with back pain

  17. 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

  18. 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

  19. 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

  20. 2007 • 9.03 DSH • 1.05 TMJ pain • 18.06 self harm hit hand • Dermatitis artefacta • 20.11 Baby Kelsey born

  21. 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

  22. 2008 (ct) • 10.09 Right radio frequency lesioning L3 L4 L5 and S1 • 15.09 Laparoscopic right and left ovarian cystectomy Inconclusive histology • 4.11 Flexible sigmoidoscopy benign polyp removed

  23. 2008 again • 5.11 USS pelvis (11th) • 11.11 Pain clinic Butrans 10 and TENS machine • 3.12 Flexible sigmoidoscopy

  24. 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

  25. 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

  26. 2009 (ct) • 13.08 Pain clinic – small dose of morphine don’t worry – will benefit from relaxation and hypnotherapy

  27. 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

  28. Notes arrived • 4 large envelopes • Summarised • Written to • Psychiatry • A & E • Gynae • Pain Clinic • OOH

  29. 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

  30. 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

  31. Remains a challenge We have added 13th and 14th pelvic USS 3 lots of TFTs, Chemistry, FBC and ESR 2 CRP 1 HVS / Chlamydia 1 Stool ALL NORMAL 1 Vitamin D level

  32. Importance of GP role Only holder of most of the information – no one else can see the overview

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