Case # 4

D.J. is a 32 year-old Caucasian male.  This is his third visit in four months to the emergency room.  He had previously come to the emergency room after being involved in an automobile accident.  The initial medical examination revealed no internal or external injuries, with the exception of a few minor bruises and lacerations.  At that time, he complained of a pain in his back, and was prescribed Percocet, an opiate-based pain medication for a 30-day period.  

One month later, D.J. returned to the ER, complaining of continued back pains and of the inability of the medication to quell his pains.  During this second visit, a psychosocial assessment performed by a triage nurse revealed that the patient was employed full-time as a salesman, lived with his girlfriend of one year, and was not particularly depressed or anxious.  Further questioning revealed a prior drug history such that the patient reported being in recovery from opiate addiction for the past 6 years.  After the assessment, the doctor refused to give him another prescription for his back pain, and D.J. made a scene and stormed out of the emergency room before a referral to the social worker could be made.

It is now three months later, and D.J. has returned to the emergency room, still complaining about back pain.  The doctor refuses to see D.J., claiming he is just trying to "get his drugs" and "manipulate the system."   D.J insists that he be seen, and is finally seen by a nurse, who notices a pink lump on his hand with red streaks spreading out and away from it.  After some questioning, the nurse finds that the lump feels hot and puffy, and "sort of hurts."  With more prompting, D.J. reports that he is tired for "no reason" though he admits his sleep and eating patterns have changed over the last few months.  He has lost a significant amount of weight since he was last in the ER and reports being less interested in things that he used to like doing.  He is still employed, although he is not sure for how long, since he reports having problems at work.  Also, he reports being kicked out of his girlfriend's house last staying with friends and in shelters for the past week.  Due to his high-risk status, he is referred by the nurse to the social worker for further assistance.