ED Case Presentation: Patient ML: “I am here to get Dilaudid”

Embed from Getty Images

CC: “I am here to get Dilaudid”

HPI: This is a 28 year old African American male who presents with a chief complaint of “I am here to get Dilaudid.” Patient is a repetitive historian and is unable or unwilling to further elaborate on his request. He simply states, “I am here to get Dilaudid.”

ROS: Patient unwilling to complete a review of systems

PMH, SHx, FHx: patient unwilling to answer questions about his history

Physical exam:

VS: T 36.5, HR 60, RR 18, BP 130/70, SpO2 99% on RA

Consitutional: this is an extremely well-developed African American male sitting on the bed in NAD. He is wearing sunglasses, a Seattle Seahawks jersey with the number #24, and a baseball cap with a version of the letter “B” on it

HEENT: NCAT, PERRLA

Neck: Supple

Chest: CTAB, nonlabored

CV: bradycardia, no murmurs

Abd: soft, nontender, nondistended

MSK: No edema, no focal tenderness

Neuro: Moves all four extremities equally, nonfocal

Psych: flat affect

Diagnostic studies: none

ED course and assessment/Medical Decision Making: This is a 28 year old male presenting with an apparent request for Dilaudid. Unfortunately, patient is unable or unwilling to further elaborate as to why he is requesting this. Despite multiple opportunities to clarify his request, patient perseverates on the phrase, “I am here to get Dilaudid.” I told the patient that absent a medical reason that Dilaudid should be dispensed, I cannot honor his request. Patient continued to perseverate on this same phrase until his watch alarm went off. At that point, he got up and walked out of the department. I told the patient that his legally mandated screening exam had not been fully completed and leaving now would constitute leaving AMA, but the patient was unable or unwilling to sign paperwork and left without his discharge instructions.

ED Diagnosis: Request for Dilaudid, unclear reason

Disposition: Left AMA from the Emergency Department

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s