In some patients, you need to question the obvious…

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In some patients, you need to question the obvious…

A 26-year-old male presents with severe chest pain that is ‘tearing’ through his back that started one hour ago. He contacts EMS and is brought by aeromedical transport from the scene where they have given him 100mcg of fentanyl and have placed him on an esmolol drip. He states he has Erlos-Danlos
syndrome and has had two previous aortic dissections, similar to the symptoms he is having now. He hands you a copy of an MRA report from a large academic institution with a finding that he has had an aortic dissection. His physical exam is unremarkable except for a midline sternotomy scar. His cardiac labs are normal and his chest X-ray (right) only shows sternal wires and a permacath.
He tells you he has a severe allergy to IV contrast, and normally gets a TEE to evaluate his aorta. The patient requires a total of 10mg of Dilaudid as well as 6mg of Versed, which barely sedates him enough to obtain the TEE, which is read as normal. He then convinces you he needs a cardiac catherization to fully evaluate his heart and aorta, so you proceed to admit him.
Your charge nurse calls the outside hospital where the patient had his MRA for additional records. The personnel of the medical records department recognize the name of the patient and inform you that the MRA report is forged. They provide you a published case report that you review, and you realize
the presentation and ED course in the article matches exactly the patient you’re seeing!  You do more research and learn that perhaps hundreds have been duped by him. A call to the cardiothoracic surgeons from the hospital where the MRA report originated confirms the patient has Munchausen syndrome. They also report that the patient neither has Erlos-Danlos syndrome nor has he had an aortic dissection, and that the patient had convinced someone to do an unnecessary sternotomy on
him. They tell you they receive a call from different doctors across the country concerning the same patient once a month. 
After obtaining all the facts, you confront the patient. He becomes very defensive and threatens to leave. You detain him long enough for a psychiatrist to come and evaluate him. The psychiatrist agrees that the patient has Munchausen syndrome, but that the patient is not interested in receiving psychiatric help. At this point, with no grounds to detain him, the patient leaves AMA. His last words
to you are, “Don’t go around spreading lies about me!” Two days later the patient presents to another local ED with the same complaint.  Luckily, one of your partners who was there the first day sees the patient and proceeds to discharge him directly home.
Physicians need to be aware of sophisticated techniques that drug seekers may use, including undergoing invasive procedures to add credibility to their story. Unfortunately, very little can be done to stop their behavior, either legally or medically. However, the diagnosis of Munchausen or malingering should always be a diagnosis of exclusion.
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