1st patient: Presents with lumps in his groin and neck with unilateral leg swelling : Dx-Malignant Lymphoma and new onset Type 2 DM thrown in for good measure.

2nd patient: Presents with intractable vomiting, jaundice, and altered mental status. Dx- Biliary Carcinoma and renal failure thrown in for good measure.

It was a long shift.

Hey Doc, I know you are a hospitalist and part of your job is to reduce unnecessary hospitalisations, consults, etc, but I have to say I beg to differ with your plan on this patient. This poor guy is 58 but is really sick. He has metastatic prostate CA with spinal mets, looks like a malnourished concentration camp survivor, has a fever of 102, grossly dirty urine, a WBC count of 19,000, a systolic BP of 89 and a heart rate of 110, and a Hgb of 7.8. I really think he is septic and needs to be admitted for fluids, antibiotics and possibly blood transfusion just to start.

I know you claim to have found all this information in his previous admissions showing that he has “chronic tumour fever”, “chronic leukopaenia”,”chronic anaemia”, and “chronically dirty urine”. I was waiting for you to say “chronic sepsis” but you didn’t. Anyway, you say you managed to convince his PMD at the nursing home that he can go back there and get his fluids and antibiotics. Well, you may have convinced him but not me. If you want to discharge him, you’ll have to do that yourself since I’d really worry about getting sued if this guy boxes.

Guess what happened? The guy got sent back and returned a day and a half later. BP in the 70′s, Hgb 5.5, fever 101, WBC 22K, and now with a creatinine of 3.5. Sometimes you have to actually look at the patient and not all that other stuff.

People with Munchausen’s syndrome are fun.  Well, not funny but hearing about the things they do to themselves on purpose to obtain medical procedures and such is fascinating.

However, when is it Munchausen’s by proxy, it gets more upsetting.  Especially when the person having all the bad stuff happen to them is a minor. Take for example the disturbing case I had of late.  A woman brings in her chronically ill 17 year old son who legitimately has a history of severe leukaemia.  He’s been through the mill with that disease and evidently has it “in remission”.  However he keeps losing weight, still needs a PEG tube, and is chronically depressed and non-functional.

He’s brought in for generalised weakness and abdominal pain. The work up shows he has a UTI and has pretty elevated BUN and CR suggesting dehydration.  He also has a pretty high WBC count making me wonder whether his leukaemia really was in remission.

Anyway, the kid remains hypotensive and the mom is a pain in the ass – up in everyone’s grille.  Asking for this and that, wanting to be transferred to a nearby world renown cancer hospital, etc, etc.   She also wants to give him (via PEG) his regular meds.  We say no, he’s sick and we need to monitor exactly what we give him and what he puts out.  Well, wouldn’t you know it the RN catches her giving the kid Lasix and Methadone (80 and 60 mg respectively)! Hello, we ain’t gonna get his BP any better with that stuff on board.

So to cut to the chase, in the end he got transferred but everyone was convinced she was inducing a lot of his symptoms and making his illness worse.  I initially wondered if she was clueless but no. I think she was doing this on purpose.  We told this to the MD who accepted the transfer and he agreed.   We made the necessary reports and we’ll see what happens. Hopefully the kid gets better no thanks to his Mom.