Karyn Butchard Lead Stroke Nurse Specialist West Herts NHS Hospitals Trust     Case Studies Not all as it seems……… Munchausen’s syndrome Further work needed         Mr A. Flynn (68) Lives in Kent – no family in UK PMH – MI(X2), warfarin (INR 1.4) Travelling on train from Rugby to Brighton 20.15 – sudden onset LSW, dysarthria A&E at 22.55, CT NAD Refused thrombolysis ( streptokinase 10 days previous) Self-discharged with inconsistent signs 4 days later          Mr. A. Hartley (68) Lives alone in Solihull – brother in Felixstowe PMH – HTN, IHD Travelling on train from Felixstowe to Solihull 20.00 – sudden onset headache, LSW Passengers called 999 CTH NAD – thrombolysed 22.30 Inconsistent signs Self – discharged 22nd Feb – fully mobile         Mr. D. Phillips (65) Lives in Dover – family in Australia PMH – prev strokes, HTN Stroke & thrombolysed 30/10 in Epsom Self discharged Train to Dover Collapsed at St Albans Brought to WGH        “Suicidal thoughts” following bereavement in 2010 Previous drug overdose Rail network to travel UK – randomly choosing destination No fixed abode Thrombolysed 18+ times Referred to psychiatric team, accepted admission to psychiatric ward Self-discharged 12 hours later          Confirmed treatment throughout UK Telemedicine Taken part in research studies Known to NHS fraud Identity fraud confirmed Scotland - London Transport police Previous “confessions” & psychiatric input Book outlining all travels and treatment Attempt at suicide is dubious     Male in his 60’s History – had a stroke while on a train Signs – may be inconsistent/fluctuate Appearance: ◦ tattoo “NZ” ◦ Missing teeth ◦ Chest burns from cardioversion       PMH – MI, PE, HTN Profession – hydraulic engineer on ferries No GP, NOK uncontactable Possessions: DVD player, large suitcase Refuses to allow inspection of possessions Aggressive if questioned and self discharges  People with factitious disorder and Munchausen syndrome , , or actually . Their aim? To assume the status of “patient,” and thereby to , , and or nonprofessionals that they feel unable to obtain in any other way. Unlike individuals who engage in malingaring, people with factitious disorder and Munchausen syndrome are not primarily seeking external gains such as disability payments or narcotic drugs— though they may receive them nonetheless. In some cases, the fabrication or induction of illness is an (Feldman)     No published cases Not difficult to fake signs High profile public campaigns Speed of treatment decisions     No published report of Munchausen’s syndrome and thrombolysis Multiple thrombolysis safe in a “normal” brain Abuse of NHS resources No national alert system available to alert ED and stroke teams  Pallis,C.A (1979) McIlroy was here. Or was he? BMJ 1979, 1, 973-975