Antoine’s pain is in his lower back, down into his legs, described as sharp and burning. No numbness or tingling. Standing, walking up the stairs makes it worse. Back flexion and decreased side flexion with bending to the right worse than the left. Point tenderness along the thoracic and lumbar spine and left and right lateral to it across the whole area. No tenderness in hips or buttocks; negative leg lifts; normal lower extremity reflexes. Normal motor strength and sensation but pain with the hip flexion and rotation.
DR. RODGERS: So, let’s talk about the exam. I noticed you have some tenderness, and you’re having trouble bending. I want to ask you a few more questions, so we can decide on the next steps.
ANTOINE: (sighs) Yeah, okay.
DR. RODGERS: So you haven’t been back home that long. How’s the transition back to civilian life been going?
ANTOINE: Oh I don’t know… it’s crazy. Between the back pain and not sleeping… I got this part-time job at the hardware store. It’s BS work, ya’ know? And now I might actually lose that job because I’ve been calling in more and more because of my back.
ANTOINE THOUGHT: I thought everything would be better once I got home… but it’s worse than ever.
DR. RODGERS: So, with your back pain and sleeping issues, what makes you feel better besides the Percocet?
ANTOINE: Oh. Well, the Percocet really helps – takes the pain away and helps me sleep. (pauses like he’s having trouble concentrating) Um, oh yeah, wait, what was I saying?
DR. RODGERS: Does anything else help with the pain?
ANTOINE: Um, just parking myself on the couch and being alone, having some beer; watching TV… trying to get back some of the time I lost when I was deployed.
COACH ADVICE: Antoine seems a bit distracted. If this continues, it could be a warning sign of some more serious issue.
DR. RODGERS: How often do you drink?
ANTOINE: I don’t know. Like, most nights… maybe five nights a week? It helps me relax.
DR. RODGERS: And, on those nights, how much do you drink?
ANTOINE: One or two six packs. Probably closer to one, maybe two. I don’t see what this has to do with my back. DR.
RODGERS: Well, knowing about your drinking patterns will help me know what kind of prescription to write for you. So tell me, how long has this been your pattern—drinking one or two six packs five nights a week?
ANTOINE: Since I’ve been back at home, I guess. But I deserve it. Those last few years weren’t easy.
COACH ADVICE: You can select “Discuss Treatment Options” at any time to move on to the next part of the conversation with Antoine.
DR. RODGERS: Antoine, I think you have a drinking problem. We can get you the help you need; let's talk together about a few options.
ANTOINE: (angry) I do not have a drinking problem. Where I come from, if you drink a couple of beers after you’ve worked hard all day, that’s no big deal. Okay?
COACH FEEDBACK: Labeling a patients’ alcohol consumption as a “problem” can make him defensive. Try expressing your concern without applying a negative label. Undo this decision and select a different option.
DR. RODGERS: And do you ever wake up and feel like you need a drink to get yourself going for the day?
ANTOINE: No.
DR. RODGERS: It’s a good sign you’re not having a drink first thing in the morning.
ANTOINE: Well, I do admit that I drink a little bit more than I did before I was deployed. I mean, I didn’t watch TV or have a beer for a long-ass time, so I think it’s pretty normal to want to come home and have a few beers.
COACH ADVICE: Telling Antoine “it’s a good sign” is a judgment, and although positive, it’s best not to make negative or positive judgmental statements when you’re gathering information.
DR. RODGERS: We’ve talked a lot about your back pain, sleep issues, and drinking patterns, and I have some things I’d like to discuss further. Let’s talk about your treatment options.
ANTOINE: Okay…
DR. EBER: Good job. You were able to uncover some stressors in Antoine’s life that might be contributing to his physical complaints—or at least diminishing his quality of life. It took you more than five minutes, but in real life, you should be able to gather enough information to determine if a patient is at risk for a mental health disorder in approximately three to five minutes.
You learned that Antoine is a veteran, suffers from nightmares, and has trouble sleeping. Antoine’s insistence on receiving a new prescription for Percocet alerted you to consider substance misuse. His alcohol consumption - typically one or two six packs of beer five times a week – is placing him at risk for harm and could indicate alcohol abuse if he’s experiencing negative consequences as a result. At times, he had trouble concentrating during the conversation. Antoine revealed that he’s been avoiding large groups of people and prefers spending time alone at home. And, Antoine seemed irritable at times during your conversation.