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    (Original post by No Future)
    Ask her, "in the past what have the doctors done to treat your shoulder?"

    Ask why she's going to see the orthopods?
    She says that they sometimes sedate her and pull her shoulders back into position, and sometimes they just pop back by themselves. She is seeing an private orthopaedic surgeon to get her shoulders sorted.
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    Has the patient received any blood transfusions in the past?
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    I'd defibrillate him then perform the heimlich maneuver before giving him a rabies inoculation.

    I'm not sure though so I'd run that past someone first.
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    (Original post by Tech)
    i'm totally stumped. all the typicals - check bp, temperature..? check reflexes, dermatomes, myotomes? keep trying to get hold of the medics at her old hospital and try and ring up the bloke she's supposed to be seeing in liverpool - she may have to wait until then?

    no more useful suggestions
    Vital signs all normal. Neurological examination unremarkable. The orthopaedic surgeon in Liverpool is asleep. The medics in Wales refuse to talk to you - "What difference does it make? She might have something completely different going on and she's 100 miles away. What exactly do you want us to do?"
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    (Original post by dentistry1)
    I'd defibrillate him then perform the heimlich maneuver before giving him a rabies inoculation.

    I'm not sure though so I'd run that past someone first.
    I'd also stick to dentistry.
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    (Original post by Dekota-XS)
    Has the patient received any blood transfusions in the past?
    No.
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    (Original post by electricjon)
    She says that they sometimes sedate her and pull her shoulders back into position, and sometimes they just pop back by themselves. She is seeing an private orthopaedic surgeon to get her shoulders sorted.
    Offer her some more morphine and play with her shoulders?
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    (Original post by No Future)
    Offer her some more morphine and play with her shoulders?
    I assume someone's already checked for uric acid..? but yeah, otherwise, definitely this.
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    You give her some more morphine but she plainly refuses to allow any active or passive movement of her arms, screaming as soon as you touch her.
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    (Original post by Tech)
    I assume someone's already checked for uric acid..? but yeah, otherwise, definitely this.
    Uric acid levels are normal
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    So currently her left shoulder AND right shoulder AND left ankle are all in excruciating pain? Or do they just alternate? When did the pain onset? Has her ankle only just started hurting?

    I'd be tempted to risk the lymphoma and get one last x-ray, then after that, combined with previous records, you have some pretty strong evidence to say she is faking it. Dubious: Maybe 'accidentally brush her arm to judge her reaction? Probably would not do this!

    The time is interesting - do addicts/munchausens typically pop along at 5am when most people would rather be sleeping? Maybe they do.

    I also find it interesting that they are going to a private surgeon. Obviously could be coincidence, but is it because the NHS have refused to treat her in the past? Would this not be in her history?

    It could be some other source of pain, maybe neurogenic, but the pain localizes to her shoulders, then when they are examined it localizes somewhere else... i don't think this is any other problem that requires investigation.

    I would take this up with her and her parents. Explain the situation - there is no evidence that she has ever had a dislocation despite numerous x-rays including 4 (i'm presuming) negative tests in the last couple of hours despite complaining of extreme pain only moments before. Whenever one area is examined the pain suddenly changes to somewhere else. She has maxed out on morphine etc and there is nothing else you can do for her if all of these dislocations miraculously heal themselves every time they are examined. Go home and see what the orthapedic surgeon says - this will provide a conclusive view as to your problems. For now, there is nothing we can do.

    If i get shouted at or threatened with GMC hearings then so be it.

    I presume this is ok having been given morphine etc - you said her O2 sats were ok.

    EDIT yeah sorry 'faking it'is wrong - i just didn't want to type munchhausen lots of times!
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    Ask her how she expects us to fix her shoulders if she wont let us touch her.
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    Call Max Pemberton!
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    So there's no one more senior to ask?
    Have Psych been called? Have they suggested anything? How do you treat Munchansens?
    Why have the x-ray department let you do 1 x-ray of each limb??
    Seeming as her shoulders are normal and she's on lots of pain meds, is there anything else you can do. Would / Could you discharge her?
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    (Original post by electricjon)
    walked out of A&E, never to be seen again.
    Thank **** for that!

    I feel sorry for the ortho guy. At least he's getting paid extra. How would he deal with her?
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    (Original post by electricjon)
    ...
    Would you bother trying to communicate with the orthapedic surgeon? Or do you think the (now quite extensive!) history plus (presumedly) more detailed examination will lead him easily to the same conclusion and lead to her getting help soon enough? Do you record something like 'probable munchhausens' on a patient history? Sorry for all the questions :

    Thanks for doing this thread btw - very interesting!
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    (Original post by nexttime)

    Thanks for doing this thread btw - very interesting!
    Ditto. Nice variety.

    Can she even be helped? I presume she wouldn't see a psychiatrist because she's "not crazy"?
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    (Original post by nexttime)
    Thanks for doing this thread btw - very interesting!
    yeah thanks a lot! great way to practice and learn!
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    Well, being a private doctor, the orthopaedic surgeon would offer his professional opinion (which would be that her shoulders are normal and that he recommend a psychiatrist for her Munchausen's) but then ultimately the patient would have the power to have whatever she wanted. If she wanted bilateral shoulder replacements and was willing to pay for it, then the surgeon would be obligated to do so.

    As for my duty of care - I reported the case to the consultant the following morning, who decided it would be best to flag up the patient's records in case she re-attended, to ensure that she doesn't get unnecessary investigation or treatment, in order to protect her from x-rays (and herself) and save the valuable resources of the A&E department. I imagine she'll just go to a different hospital and do it all over again, such is the nature of Munchausen's. Perhaps one day she'll agree to a psychiatrist...
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    Paracetamol.
 
 
 
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