MARRIAGE COUNSELING???

It was the middle of the afternoon and my clinical day was almost over. So far it had not been a bad day but I had not seen anything different than what I had seen before. The next chart was up in the slot located outside the exam room door. I looked at the chief complaint. I know the staff that answered the phone and set up the appointments did not have a lot of medical education except for what they did and heard in the office. I read the chief complaint and it said, “I am having a nervous breakdown.” I looked at the age and sex of the patient. It was a 22-year-old female who’s name was Sandy. I glanced at the medication list and saw Wellbutrin listed as the only prescription medication. I looked at the closed exam room door. My gut feeling told me I was just about to get the “different” situation I was looking for.

I lightly knocked on the door before entering. As I walked inside I noticed Sandy sitting on the exam table and a male sitting on the bench reading a magazine. She was nice enough and smiled as I introduced myself. He continued to look at the magazine. His right leg was crossed over his left leg and moving back and forth. I sat down on the roller stool to start obtaining the history.

“So what brings you in the office today?” I asked.

“I am always angry and have anxiety,” said Sandy. She looked at the male sitting on the bench. He continued to look down at the magazine. I had the feeling there was some tension in the room between the two.

“When do you feel angry?” I asked. My pen was getting ready to write the subjective part of my SOAP note.

“When I am around him I just get angry and feel anxious. He is my husband,” said Sandy as she pointed towards the male continuing to read the magazine.

“Do you feel like this at any other time during your day? Like at work?” I asked.

“No. Just around him. When I am around him I just want to explode! He just pisses me off!” she said. Her husband continued to read the magazine. His leg was moving faster. I started to write my note.

“I just don’t know. Every time I am around him I just get mad. Plus he doesn’t help any by making things worse,” said Sandy.

“Why don’t you tell her the whole story?” said her husband. I looked at him because it was the first time he spoke. Even with talking he continued to look down at the magazine.

“Be quiet or I will ask you to leave!” said Sandy.  Her husband then looked up from his magazine.

“If I leave you will have to find another ride home!” he loudly said.

“Yeah whatever. The police were at our house a few times,” said Sandy. He looked down once again at the magazine. I sat on the roller stool trying to figure out what part of this I should write down.

“Police? Was it a domestic violence problem?” I asked.

“Yes,” said her husband. Sandy once again gave him the evil eye. It appeared there was not a lot of love in the relationship.

“How long have you been married?” I asked.

“Two years,” said Sandy.

“How long did you date before you got married?” I asked.

“Not long enough,” said Sandy. Her husband made a smirking sound as he looked at the magazine.

“Have you thought of marriage counseling?” I asked.

“Yes I have. But he won’t,” said Sandy. Both of their legs were rocking back and forth. I felt if I was not in the room they would probably go at like they did at home when the police were called.

“I just feel like I need some medication or something to help me feel less angry and anxious. Especially around him,” said Sandy. I wrote that down.

“You can say that again!” said her husband continuing to look down at the magazine.

“Oh Lord,” I thought to myself.

“Why don’t you just tell her everything?” said her husband. I knew that would provoke another response within seconds.

“I swear I will ask you to leave. This is my appointment and I allowed you to be in here if you stayed quiet,” said Sandy.

“Okay…” I thought to myself. I remained on the roller stool. Her husband continued to look down at the magazine. I saw Sandy was getting agitated because her foot was moving and she was sitting more upright. She looked right at him with angry eyes as he continued to stare down at the magazine.

“Don’t tempt me. If I leave you will have to find another ride!” said her husband. I needed to change the subject and quick.

“Why are you on the Wellbutrin?” I asked. I was wondering if there was some sort of connection.

“To quit smoking,” said Sandy.

“Oh. Well there goes that theory,” I thought. “How long have you been on it?” I asked.

“About two weeks. I know it takes more time,” said Sandy.

“Has it worked for you?” I asked. I wrote that down. I put down under general objective, “arguing with husband during history taking.”

“I am down to two cigarettes a day. I have not had the urge so I guess it is working,” said Sandy. Her husband continued to look down at the magazine.

I did the physical exam and everything looked normal. I looked back at her husband and he continued to look down at the magazine. It was a funny thing how the pages never turned. I guess he just needed a distraction from his wife. It was time to go talk to my preceptor. I excused myself and closed the door. The thought of hearing things crash against the wall came to mind. I wondered if I would need the medical assistant to call 911. I could not believe the amount of anger in that room.

While discussing counseling and medication options for Sandy, her husband opened the door and told me he was out of there and he could not take it anymore. I had the feeling Sandy would need to find another ride home. My preceptor and I both looked at each other. It was time to go into the room with Sandy. It hopefully would be easier to get a good history without the bickering back and forth.

Sandy told us while in the exam room her husband was hitting her. She had no obvious bruising or trauma to her body. I believed they just fueled each other during their arguments. He coaxed her as she coaxed him. Marriage counseling was discussed once again. Sandy said she wanted to but her body language said otherwise. She once again discussed going on a medication to help with her anger and anxiety. My preceptor thought Prozac would be the medication of choice and to wean the Wellbutrin before completely quitting. It was felt smoking cessation was not the priority at the time. Finding separate places to stay for a while was also discussed with agreement from Sandy. She told us her husband had been sleeping on the couch for a while. Sandy was asked if she wanted to harm him or herself. She said no. A prescription was written for Prozac with a follow-up in two weeks. Sandy told us she would stay at a friend’s house and would be away for Christmas for a couple weeks without her husband.

I had the feeling the police would probably be at their home more in the future. I also hoped the Prozac would help with her anger problem before their marriage ended if they did not receive counseling. I told my preceptor I did not believe the marriage would survive. There was too much hate in the room and there was no one pill that could help it.