For Examiner Only Case Minor complaint with substance abuse issues Author; John Rose, MD Reviewer; Douglas Char, MD Approved; 10/26/05

Transcription

1 For Examiner Only Case Minor complaint with substance abuse issues Author; John Rose, MD Reviewer; Douglas Char, MD Approved; 10/26/05 CONTENT AREA Psychiatric/ Behavioral/Substance abuse ORAL CASE SUMMARY SYNOPSIS OF CASE 29 year male presents with a chief compaint of several small skin abscesses. Evaluation reveals that the patient has a signinficant methamphetamine abuse problem. He has recently lost his job as civil engineer and his wife has left him due to fear of of his erratic behavior. The wife is in the waiting room, however. She brought him to the ED for evaluation worried about his worsening substance abuse. SYNOPSIS OF HISTORY 29 year male presents with complaint of multiple skin abcesses. Patient concerned that he might have "bugs" in his skin. Patient states that new people have moved into his building and they are spreading bugs. Patients history is somewhat tangential and he exhibits symptims of chronic sympathomimetic abuse. Ultimately, the patient reveals his escalating methamphetaime abuse. Patient has recently lost his job over his drug use and his wife has left him. She is in the waiting room and able to give further history about his worsening substance abuse and that he is buying "meth" from a friend down the street. He ultimately agrees to go to treatment program from the ED. SYNOPSIS OF PHYSICAL Patient is jittery and has difficulty concentrating. His skin has a few small putules with local erythema. He has evidence of intravenous injection. He has no murmur and is afebrile. He is alert and orients with no hallucinations or suicidal or homicidal ideations currently. CRITICAL ACTIONS 1. Identification of substance abuse problem 2. Obtaining complete history through wife 3. Evaluation for complications of chronic IV methamphetamine abuse (such as endocarditis) 4. Treat for cellulitis SCORING GUIDELINES (Critical Action No.) Score down if if examinee fails to assess for suicidal or homicidal ideations. Examinee should also question regarding domestic violence. Need to address the issue of cellulitis and rule out skin popping abcsess (IV drug use) or signs of systemic infection which could explain some of patient s symptoms, behavior FOR EXAMINER ONLY

2 For Examiner Only PLAY OF CASE GUIDELINES (Critical Action No.) 1. Examinee determines that patient complaint is inconsistent and considers alternative differential including substance abuse. 2. Questioning regarding substance abuse-may use CAGE questions or other substance abuse screening system. pt became addicted several months ago and began using iv methamphetamine. Began using at work and was fired. Initially says that he can stop whenever he wants. 3. Examinee will need to include wife in discussion to understand full extent of substance abuse history including losing his job as civil engineer and erratic behavior. He stays out late and frequently stays up all night. He has been sleeping more during the day. He says he doesn't have problem. 4. Evaluate for complications-check temperature, neuro exam, cardiac exam 5. Update tetanus 6. Involve mental health professional to help with evaluation and arrange voluntary inpatient drug rehabilitation. Patient ultimately agree to intervention. FOR EXAMINER ONLY

3 For Examiner Only Critical Actions 1. Identification of substance abuse problem This critical action is met by identification of addictive behaviors-denial, escalation, guilt, rationalization, loss of social support, avoidance behavior Cueing Guideline: 2. Obtaining complete history through wife This critical action is met by interviewing wife to clarify disprepancies in the history and worsening substance abuse. Cueing Guideline: 3. Evaluation for complications of chronic iv methamphetamine abuse This critical action is met by a complete physical exam focusing on skin, cardiac, neurologic systems Cueing Guideline: The nurse informs you that the patient temperature is elevated on repeat exam 4. Treat local skin infection (cellulitis) This critical action is met by providing antibiotics to cover common skin organisms and making sure he has medical as well as psychiatric follow up. The small abscesses do not need to be incised and drained at this time Cueing Guideline: Hey doc, what about the rash?

4 For Examiner Only History Data Panel Age: 29 yrs Sex: male Name: Daniel Davis Method of Transportation: Private car Person giving information: Patient Presenting complaint: "Things in my skin" Onset and Description of Complaint: Symptoms started 1 week ago after a new neighbor moved in. States he noted multiple furuncles to his forarms an believes the "are bug crawling in them." Lesions are slightly puritic. Start with erytmematous base and develop into pustules. Patient states he wnat an antibiotic to kill the "bugs." Past Medical History Allergies: none Medical: none Surgical: appendectomy at age 12 Last Meal: 3 hours ago Habits Smoking: no Drugs: marijuana only admits to shooting up methamphetamine after prompting and intervention with wife Alcohol: occasional Family Medical History Father: alive well Mother: alive well Siblings: 1 sister well Social History Married: yes, married 2 years, recently separated Children: 1 year old boy Employed: worked as a civil engineer. Recently laid off (partly due to poor performance) Education: BS in engineering PMD: none

5 For Examiner Only Physical Data Panel General Appearance: Alert, sitting up on gurney, picking at his arms. Attire is somewhat unkempt. Vital Signs: BP : 144/90 P : 108 R : 20 T : 37.1 C O 2 Sat : 98% Glucose : 104 Neurological: patient appears a bit anxious, pacing the room, keeps checking his watch for the time and looking around the room Mental Status: Alert, oriented to self place and time Head: Normal Eyes: pupils 5mm reactive Ears: normal Mouth: teeth generally maintained though some tooth fractures are noted Neck: normal Skin: numerous small pustules with erythemtous base noted over volar aspect of forearm. Some scattered escoriations are also noted. Numerous small echemotic areas are noted in the antecubital fossa and deltoid area Chest: clear lungs, normal exam Heart: tachycardic, s1 s2, no murmur or rub Abdomen: normal Extremities: as above Rectal: pt refuses Back: normal, non tender FROM Neurological: Alert, somewhat jittery, speech a bit pressured at times, thoughts tangential. Strength 5/5, gait normal, denies homicidal or suicidal ideation. Denies hallucinations but notes that he might have bugs crawling under his skin. Other exam findings:

6 For Examiner Only Stimulus #2 CBC WBC 9.0 /mm3 Hgb 13.6 g/dl Hct 40 % Platelets 256 /mm3 Differential Segs 72 % Lymphs 24 % Monos 3 % Eos 1 % Lab Data Panel Stimulus #5 Ethanol level Urine Drug Screen and Stimulus #3 Chemistry Na+ 140 meq/l K+ 4 meq/l HCO 3-25 meq/l Cl- 102 meq/l Glucose 106 mg/dl BUN 12 mg/dl Creatinine 0.5 mg/dl Stimulus #4 Urinalysis Color yellow Yellow Sp Gravity Glucose Protein Ketone Leuk. Est. Nitrite WBC /HPF RBC /HPF

7 For Examiner Only Stimulus Inventory Stimulus #1 Emergency Admitting Form Stimulus #2 CBC Stimulus #3 Chemistry Stimulus #4 Urinalysis Stimulus #5 Drug screen and ethanol level Stimulus #6 Stimulus #7 Stimulus #8 Stimulus #9 Stimulus #10 Stimulus #11 FOR EXAMINER ONLY

8 Mock Oral Feedback Form Date: Examiner: Examinee: Data acquisition Problem solving Patient management Resource utilization Health care provided Patient Interpersonal relations Comprehension of path physiology Clinical competence (overall) Critical Actions 1. Identification of substance abuse problem 2. Obtaining complete history through wife 3. Evaluation for medical complications of chronic iv methamphetamine abuse 4. Treat skin infections cellulitis, minor abscesses FOR EXAMINER ONLY Dangerous actions and omissions Failure to assess for suicide or homicide risk or issues of domestic violence

9 Mock Oral Feedback Form Core Competencies Date: Examiner: Examinee: Does not meet expectations Meets Expectations Exceeds Expectations 1. Patient care 2. Medical knowledge 3. Interpersonal skills and communication 4. Professionalism 5. Practice-based learning and improvement 6. Systems-based practice Critical Actions 1. Identification of substance abuse problem 2. Obtaining complete history through wife 3. Evaluation for medical complications of chronic iv methamphetamine abuse 4. Treat skin infections cellulitis, minor abscesses FOR EXAMINER ONLY Dangerous actions and omissions Failure to assess for suicide or homicide risk or issues of domestic violence

10 Stimulus #1 ABEM General Hospital Emergency Admitting Form Name : Daniel Davis Age : 29 yrs Sex : male Method of Transportation : Private car Person giving information : Patient Presenting complaint : "Things in my skin" Background: States that he noted "bugs" in his skin. Wants antibiotic to "kill them." Vital Signs 140/ C

11 Stimulus #2 CBC WBC 9.0 /mm3 Hgb 13.6 g/dl Hct 40 % Platelets 256 /mm3 Differential Segs 72 % Lymphs 24 % Monos 3 % Eos 1 %

12 Stimulus #3 Chemistry Na+ 140 meq/l K+ 4 meq/l HCO 3-25 meq/l Cl- 102 meq/l Glucose 106 mg/dl BUN 12 mg/dl Creatinine 0.5 mg/dl

13 Stimulus #4 Urinalysis Color yellow Yellow Sp Gravity Glucose Protein Ketone Leuk. Est. Nitrite WBC /HPF RBC /HPF

14 Stimulus #5 Drug screen and ethanol level Urine Drug Screen Opiates negative Marijuana positive Benzodiazepines negative Amphetamines positive Cocaine negative PCP negative Ethanol less than 10 mg/dl