Monday, June 11, 2012

Patient #2: "Pregnancy"

     Here is the second of several profiles depicting patients typical of my medical practice.  The descriptions are composites and cannot suggest the identity of any particular patient.
     Ms. B. is in her mid-twenties and complains of abdominal pain.  She wants pain pills.  She tells me I have no idea how much pain she is in. The pain pills that "have always worked best," she says, are oxycodone, which she got from prior urgent care clinic doctors.  I do a physical assessment including a pelvic exam and urine test and discover that she is pregnant for the sixth time.  Moreover she has a urinary infection and gonorrhea.  Her urine drug screen shows marijuana and cocaine derivatives.  She went to the ER last night but had to wait six hours to be seen, so she left and came to my office instead.  "Why did you go to the ER last when you knew we were open today?" I ask her.  I have previously insisted that she stop making weekly visits to the ER for pain since she cannot see the same doctor there or benefit from continuity of care.  She says it's because she had unbearable pain. "You doctors just don't get it!" she  shouts at me, and then starts to cry.
     Her mother takes care of the children most of the time.  Her husband is not present today.  He is unemployed, nevertheless he's come along at only two of her last 14 visits--times when he also had an appointment.  The marriage is in jeopardy she tells me, as the father of this pregnancy may be another man.  She thinks she might get an abortion; therefore, she says, it would be okay for me to prescribe pain pills.  She has hepatitis from prior intravenous drug use.  Under duress from me she has just finished treatment with a specialist for cervical cancer.
      I do all the correct tests--HIV, blood count, pelvic ultrasound, liver enzymes--but the bulk of the visit is centered around the health of this new baby and the need for drug rehabilitation.  Ms. B. says she doesn't have a drug problem.  She doesn't know how the cocaine got in her urine test.  She says maybe it's an error perpetrated by my nursing staff.  I treat her urinary infection and gonorrhea and prescribe a prenatal vitamin.  Her insurance--a  new Medicaid HMO--is not accepted by a single obstetrician in the area.  I wonder if I need to contact child protective services because her drug problem is affecting an unborn child.  But the last few times I called this agency for a serious problem it took 30 minutes to give a report.  A representative made one visit to the home, filed paperwork, and closed the case.
     I spend more than an hour with this patient, decline her request for pain pills again, and ask her how she sees herself in five or ten years. I am hoping to inspire a different motif for her life.  She is creative, has innate intelligence, and could benefit from job training--can she see herself off welfare and pursuing a career?  Or does she want to remain a drug addict?  "How many times do I have to tell you, I'm not a drug addict!" she shouts, and storms out of the office.

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