This is his fifth visit to the emergency room in the last month alone; he was only 25 but has been hospitalized for most of his adult life. His hospital file was as thick as an encyclopedia and read like a “Wikipedia” for medical diagnosis. From cardiac arrhythmias to pulmonary emphysema almost every organ in his body has been diagnosed and treated for one disease or the other. He has had three emergency surgeries in the past 2 years alone and all of them were inconclusive.
Today he was complaining of a left flank pain that migrated to the left groin, he said the pain was so severe that he couldn’t sleep. He was actually sweating profusely during the conversation with the doctor and was clutching the left side of his abdomen. The doctor prescribed strong analgesics for him, placed him on admission and wrote up a series of tests to confirm his presumptive diagnosis, since the signs and symptoms were classical for the disease in question.
When he came back to review the test results, he noticed the patient was more comfortable. He was chatting with the nurses and appeared to be pain free for the moment. On review of the test results they were all normal which surprised him. The symptoms were so classical and the information he got from the patients history corroborated his clinical diagnosis. He was intrigued. This will be his first posting in the course of his nephrology residency and he is getting this puzzle for a case. Believing his diagnosis was right and that the test results might have been screwed up somehow, he began treatment and ordered for more comprehensive tests.
It was alarming when those too came back normal. From the CT scan to the electrolyte panel, the MRI he even did a urography study and all of them came back normal. Now intrigue was replaced by confusion and he sat down to study the patients’ hospital file in greater detail.
Of all his admissions majority of the diagnosis has never been confirmed by any tests, the tests have been normal but he has still had symptoms that were pointing to specific diagnosis. It was as if the standard for making a diagnosis in this patient’s particular case has become the patient himself and not the different test panels that have become the gold standard over the years.
He also noticed from the file that in the beginning the patient used to demand for admission even if the attending physician or surgeon did not find it necessary. In his quest for answers, he spoke with one of the nurses that the patient usually converses with, trying to know his state of mind. She told him that he never has any visitors that he usually feels at home in the hospital and always feels sad when discharged. It was almost as if the hospital environment was satisfying an emotional need.
That struck a nerve in him and it all started coming together. Classical symptoms that are specific for the diseases concerned ,frequent hospitalizations, medical tests that were almost always normal irrespective of active symptoms ,surgeries that were inconclusive at best, no family connections and some other small factors that were pushing in a particular direction.
He knew what he had to do but he lacked the power to do that, so he booked an appointment with the head of Nephrology. The task before him is immense very difficult to prove, has no test panels that can help him and he is standing alone in his decision. He was practically trying to prove that the poster boy for good patient behavior in the hospital was lying about not just his present symptoms but all the other ones before that.
He was going to prove that the man had Munchausen Syndrome; the only problem was that he was going to prove it to scientists and clinicians who deal in empirical evidence and not probabilities.