If I wrote the questions for the boards

1) A 24 year old male walks into your office. He is 40 minutes late for his appointment. He begins to talk loudly at the check-in so he is brought back to spare the other patients. On questioning he reports that his chronic back pain is worsening and his roommate has stolen his pain medication. Now what?

2) A 60 year old divorced woman is seen for “fatigue”. When you ask her how she is doing she begins to cry. She states that she is losing her job, and her sister, with whom she lives, is suffering from dementia. The patient’s salary pays for their living expenses and the job provides the patient with health insurance. She has insulin-dependent diabetes and peripheral vascular disease. She went to a social worker who told her that she would have to sell her house before qualifying for Medicaid. Now what?

3) A 52 year old man with a history of alcohol abuse comes to see you after being released from the hospital. In the hospital, two drug-eluting stents were placed as treatment for an acute myocardial infarction. He was sent home with five prescriptions, one of which is clopidogrel. The cost of this drug is $200 monthly and he lives off money from odd jobs. He is functionally illiterate. Now what?

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9 Comments

  1. G Grace

     /  April 25, 2012

    Easy. The answer to all three would be: consult psych.

  2. THAT guy who says things

     /  April 25, 2012

    I would refer them all to a libertarian.
    They’d be told to suck it up and quit leeching off of producers.
    Health care is a rationed privilege…them slips of paper in your wallet with pikshures of old white men on them are your ration coupons.
    Be sure to tell each patient to stop smoking and have a nice day!

  3. Marnie

     /  April 25, 2012

    What next?
    They go deeper and deeper into debt, while failing to fill any prescriptions. They forego preventative care and then are forced to go to the emergency room when their situation is dire. They suffer needlessly. Being already hugely in debt, we, the taxpayers, pay far more than we would have to cover the expense of their emergency room visit than we ever would have in covering a plan that would have afforded them access to routine healthcare and prescriptions.
    Everyone loses.

  4. It’s never Lupus….is it? If not then put “B”.

  5. Dianne

     /  April 25, 2012

    Patient #1: Differential diagnosis: Roommate stole meds versus patient is addicted versus patient is pseudoaddicted (needs more pain meds than he’s getting so acts kind of like an addict, but wants the drug for pain control not partying) versus patient is selling meds. With or without roommate’s help. Discuss why you can’t simply refill the prescription every time he asks, including the DEA’s likely response to frequent narcotic prescriptions. Explore whether he’s willing to discuss possible addiction issues. Ultimately, refill the prescription for a short period of time and check a drug screen in 1 week (should be positive for opiates…if it’s negative he has some explaining to do.)
    Patient #2: Social work consult. Might as well check a TSH, but her fatigue is due to overwork and depression. Maybe advise her to put the house in her sister’s name so she can qualify for medicaid. Get her counseling, somehow, from somewhere. Also respite care. How bad is her sister? Do you need to discuss nursing home placement?
    Patient #3: Beg the drug companies for free meds for patient. If that doesn’t work, threaten the drug companies: “be a shame if I have to go back to using ticlopidine, wouldn’t it?” Most will cave. But are you sure about heavy platelet inhibition in an alcoholic? Well, too late now: if he wasn’t a candidate for anti-platelet therapy, the stint shouldn’t have been placed. Now it’s anti-plt therapy or good-bye stent and possibly heart…

    Alternate answer: Take that job offer in Alberta.

  6. DLC

     /  April 28, 2012

    Tell all of them to get a haircut and get a real job. Or: 1) is he drug-seeking for pain, perceived pain or to make money ? 2) she’s screwed. transfer the house to the sister’s name, have the sister declared incompetent and then rent the place from her, having the sister accept “services rendered” in lieu of rent. Then apply for assistance. It’s gaming the system and might not work in your area. (as to why you should *have* to game the fucking system, I’ll leave that to yours or Ayn Rand’s imagination) 3 ) sample the guy the clopidogrel if you can. then get him down to the welfare office to apply for medicaid. He probably won’t qualify unless he lies about his income. Bill him for the office visit and have him include that in his presentation of evidence to medicaid. Curse Mitt Romney, Ayn Rand and the Republican Caucus in congress.

  7. Barbarella

     /  May 5, 2012

    I thought that by not being a doctor, I could avoid these crises of conscience. So I began working at a library and now I teach illiterate adults, repair books and DVDs destroyed by behaviorally disturbed children, and nudge homeless people towards the exit when the library closes. Our world is more complex that can be imagined when you are an innocent college student who only wants to pick a profession and change society.

  8. 1) Tell him, as sarcastically as possible, “Oh, he stole your meds? That dastardly scum. Well, we’ll have to call the police to see if we can get those pills back.”

    The other two are, um, this is, in the words of Officer Krupke, a social disease.

  1. The boards can bite me « White Coat Underground
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