1. equip

2. equip 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

3. equip I want to tell you a story John Guy

4. equip 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

5. equip 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.

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

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

8. equip 1983 discharged from paeds follow up 1989 tonsillectomy

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 equip 1994 Withdrawn - referred for paeds opinion Missing a lot of school c/o severe headaches – CT scan normal Breathing problems ?asthma –Responded to pulmicort Eating a concern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

10. equip 1995 Paracetamol overdose - saw CFCS once (Step sister divorced - 6 children)

11. equip 1997 6.1 Pelvic USS normal (1 st ) 19.5. Emergency admission abdo pain - USS normal (2 nd ); Treated for PID 29.8 Seen by CFCS ‘finding it hard to be listened to regarding her worries

12. equip 11.9.97 Emergency admission dysfunctional bleeding USS normal (3 rd ) Weight loss noted living on bag of crisps and Kit Kat Rx dietary supplements but worried re body image

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

14. equip 1999 Anorexia nervosa 15.1Abdo pain PV bleeding USS normal (5 th ) 2.6Overdose 9 tablets Mefenamic acid in Skegness Tale of man in Essex threatening to assault her 13.6USS normal (6 th ) 1.9‘raped’ under death threat over 9m in Skegness owner of karaoke bar Back injury

15. equip 2000 15.3Satisfies incapacity test 31.3GI endoscopy normal 27.7USS abdo normal (7 th ) 28.7 Overdose admitted to Linden Centre –20 units alcohol per day –3 sisters (went up to 4 sisters by December) 9.11Lumbar spine Xray normal (1 st ) 21.12Married

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

17. equip 2002 19.2USS normal (8 th ) 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

18. equip 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

19. equip 2003/4 03.03 Smoke inhalation house fire 06.03 Catheter inserted for acute retention 02.04says was told has emphysema - histrionic when chest assessed –CXR normal

20. equip 2006 12.04Mother died aged 59 bronchopneumonia 01.06DSH 20.07USS normal (9 th ) 01.08DSH 20.09 Facet joint injection Bankruptcy proceedings 01.11infective exacerbation of asthma

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

22. equip 2008 13.02Mirena inserted 01.03OOH Heavy vaginal bleeding post coil fit Seen by Gynae - ward attender 11.05 OOH Painful abdo lump today Rx Doxycycline 11.06 USS pelvisNormal (10 th ) 11.07120mg Depo-med and 5ml LA to abdo wall

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

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

25. equip 2009 18.03USS pelvis normal (12 th ) 30.03Psychiatrist concerned re prescriptions of opiates 01.05GP concerned re increasing doses of morphine from pain clinic 10.06Joined our list

26. equip 2009 14.06Admitted via OOH headaches and scalp lumps – dermatitis artefacta 02.07Our concern re morphine prescription – noted partner does not work as is full time carer – Secondary gain +++ 16.07Noted low threshold for pain

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

28. equip 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

29. equip Notes arrived 4 large envelopes Summarised Written to –Psychiatry –A & E –Gynae –Pain Clinic –OOH

30. equip

31. equip 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

32. equip 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

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

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

35. equip