DEATH BY TOILET PAPER

I was doing my clinical time in a family practice office. This was a busy office and the nurse practitioner regularly saw 30 patients a day. I was looking forward to some good experiences to build on when I start practicing on my own next year. Usually while in clinical I take the chart and see the patients on my own, then collaborate with the practitioner shortly afterwards. I am still in the learning mode and know I have a lot to learn. After discussing the patient we both go back into the room to see the patient where the practitioner may ask more questions or go with what we had discussed previously. We then give them their prescriptions, instructions, follow-up…etc.

Most of the patients coming in today had the same complaints of earaches, sinus pressure, cough and congestion. The prescriptions written were antibiotics and decongestants. I looked at the chart of a 30-year-old woman waiting in room 4. The chief complaint today was hearing her parent’s voices. This should be interesting. I walked into the room and introduced myself. I shook her hand and sat down on the roller chair next to the chair she was sitting in. She was a very thin frail looking woman who looked older than her stated age. Her hair was long and uncombed and clothes were wrinkled.

“What brings you in today?” I asked her. I noticed she was very fidgety. She was moving her hands frequently in her lap. Her eyes would briefly look at mine then she would look away.

“I hear my parent’s voices. I know they are in the room next door.”

“I can assure you they are not in the room next door. How long have you been hearing your parent’s voices?”

“For about a week. Are you sure they are not in the room next door?”

“I can assure you they are not. Where do your parents live?”

“They live in Idaho.”

“Are they in town with you right now?”

“No. But I keep hearing their voices.”

“What kind of over-the-counter and prescription medications are you taking?”

“I am not taking anything except Tylenol when I have a headache.”

“Do you drink alcohol?”

“I used to drink a lot more, but a week ago I cut down to a half of case a beer a day.”

“How much did you drink before that?”

“Usually a case. I thought I was drinking too much and needed to cut back.”

“Do you use any kind of street drugs?”

“I cut back on crystal and marijuana.”

“How much crystal and marijuana did you use before you cut back?”

“Usually a couple of joints a day and a few hits of meth.”

“Now how much do you use now?”

“I cut back to one joint a day and a couple of hits. Are you sure my parents aren’t in the room next door?”

“No they are not in the room next door. Have you ever thought about killing yourself?”

“I did the other day.”

“Did you have a plan?”

“Yes. I thought about hanging myself with toilet paper.”

“Did you actually do it?”

“No. I really don’t want to kill myself.”

“Have you told anybody about the way you are feeling?”

“I called the psych office down the street the other day and I have an appointment for next week.”

“Do you live by yourself?”

“I have a boyfriend. We live together.”

“Does he know how you have been feeling?”

“No. I told him once and he just blew me off.”

“Is there anybody else you can talk to?”

“I have a girlfriend but she has a new boyfriend and I don’t see her much.”

I asked her about any signs or symptoms of respiratory, cardiac, neuro problems. An examination was done. I found nothing unusual except her heart rate was high. She was still very fidgety and moving her hands in her lap.

“Is there anything else you would like to talk about?”

“Nothing else. I still hear my parent’s voices. I know they are not in the building but I do.”

I excused myself from the room and talked with the nurse practitioner. We both thought it would be a good idea to get her into the psych facility she had an appointment with today as soon as possible for an evaluation. A phone call was made and they were willing to see her within the hour. Transportation arrangements were made to make sure she showed up for her appointment.