Donna is a 45 year old woman with a past medical history of HIV infection, IV drug use, and anal cancer who was escorted to the clinic by a shelter staff member after complaining of a fall. The staff member states that Donna reported right knee pain and “torn ligaments,” and was asking for “some percs” (Percocet: acetaminophen+oxycodone) to ease the pain. When I initially question Donna about her fall, she tells me with pressured speech that she slipped while walking indoors, but denies landing on her knee. However, a few minutes later, when asked the same question, she says she fell out of her chair in the dining room and did hit her knee.
Donna has a history of IV drug use (heroin) from which she claims 6 months of sobriety and for which she is on 70mg of methadone daily. Likely from her IV drug use, she has HIV infection, for which takes daily triple antiretroviral therapy and has steady follow-up with her HIV specialist at a local academic medical center. She also reports a history of anal cancer, for which she is currently undergoing radiation therapy. Notably, Donna denies any history of musculoskeletal problems or surgeries. She undergoing the housing process with the help of shelter advocates, and currently lives with her boyfriend, who she adamantly insists “does not do drugs, and is going to be lawyer.”
On exam, Donna is initially alert and irritable with psychomotor agitation. However, while sitting in the exam room, she becomes progressively more somnolent with slurred speech to the point of dozing in and out of sleep. Examination of her bilateral lower extremities reveals multiple linear scars over her anterior lower extremities and knees that Donna admits are from “shooting up.” Her right knee is slightly more erythematous and enlarged compared to the left, with a small effusion over the anterior/proximal aspect of the knee but without bruising or deformity. Passive and active range of motion in the right knee is otherwise normal, and Donna is able to bear weight without significant pain or presence of antalgic gait. The most likely diagnosis was a ligamentous sprain.
Donna is a woman with an acute medical complaint in the context of a complex medical background including IV drug abuse. In fact, her symptoms suggest continued drug use despite claims of sobriety. From her, I learned the importance of prioritization. Oftentimes with intoxicated patients, medical, social, and psychological issues cannot be adequately addressed on the spot. While it may be appropriate to assess Donna’s desire to achieve sobriety and her barriers to success, such matters should be addressed when a patient is sober and lucid. Luckily, Donna is well-connected to her HIV specialist, as she knew both her doctor’s name and location. Therefore, in this specific situation, we decided to address Donna’s acute medical issue by resting and icing her right knee and providing non-steroidal anti-inflammatory medication. However, knowing that she frequents the shelter, I made a mental note to check-in with Donna the next time I see her. I’ll keep my fingers crossed that next time she will be more able and willing to talk about some of the important medical issues in her life…
No comments:
Post a Comment