Case Presentation: A 27-year-old woman with reported sickle-cell disease, protein C deficiency, pulmonary embolism (PE), and recent methicillin-resistant Staphylococcus aureus (MRSA) bacteremia was admitted for sickle cell crisis. She was flying between the east and west coast to visit family when she experienced chest pain 45 minutes into the flight. It was sharp, 7/10 in intensity, constant, substernal, and non-radiating. She felt the pain was similar to her sickle-cell pain. The pain continued to build despite acetaminophen and the plane was diverted for her hospitalization. She mentioned that during prior hospitalizations for sickle cell pain crisis that she required morphine patient-controlled analgesia (PCA). She also stated that she was hospitalized 1 month prior for MRSA bacteremia initially treated with vancomycin and later transitioned to daptomycin requiring a chest port. The admitting resident started the patient on IV fluids, morphine as needed for pain, and her reported previous medications including hydroxyurea, warfarin and daptomycin. The patients care was subsequently transferred to a hospitalist. Several discrepancies started to appear when the hospitalist tried to confirm the patient's history. Her self-identified hematologist stated that his testing failed to show sickle-cell trait or disease. Testing at our hospital also had a normal peripheral smear without sickle cells and a negative sickle cell screen. Calls and record requests to the outside hospitals and pharmacies the patient identified were unsuccessful. When confronted with these inconsistencies, the patient became tearful and stated, 'I know what I have.' She then gave a different name and birthdate. The diagnosis of bacteremia one month prior was confirmed, but the organism was methicillin-sensitive (MSSA). Given the inability to corroborate the patient's reported medical history, antibiotics and analgesics were discontinued, and the patient was discharged. She has not reappeared in our medical system. Discussion: This case is one of simulated illness. The differential diagnosis includes factitious disorder, malingering, and delusional disorder. Factitious disorder behaviors are unconscious and motivated by a need to assume the sick role. Malingering behaviors are based on a conscious desire to achieve external gains. Delusional disorder is a psychiatric diagnosis characterized by disordered thinking that results in misinterpretation of events. In this case without a clear external gain identified, factitious disorder is presumed. The confirmation of the patient's history was key in this case in both identifying the incorrect prior diagnoses as well as avoiding further harm in continuing hydroxyurea and daptomycin in a patient who has neither sickle-cell disease or MRSA. Conclusions: Physicians are taught to believe a patient's story, but this case highlights the importance of verification in confirming details in order to exclude factitious disorder or malingering.'
Worsham A.; TRUST BUT VERIFY: WHEN BELIEVING THE PATIENT LEADS THE DOCTOR ASTRAY [abstract]. Journal of Hospital Medicine 9 Suppl 2 :684 [http://www.shmabstracts.com/abstract.asp?MeetingID=800&id=110982&meeting=JHM201403]