Case 15: Craig Kelly

INSTRUCTIONS FOR THE DOCTOR

This is a short case.

Please take a history from Craig. Examination findings will be available from the facilitator. You are expected to tell Craig the most likely diagnosis and negotiate a management plan with him.

Craig filled out a new patient questionnaire with the following information:

• Past medical history

• Kidney stones

• Current medication

• Nil regularly

• Allergies

• Nil

• Immunisations

• No idea

• Social history

• Smokes 10 cigarettes per day

• Unemployed.

INSTRUCTIONS FOR THE PATIENT, CRAIG KELLY

Over the past few years you have become dependent on oxycodone 5 mg tablets, which you take several times per day. You see multiple different doctors every week trying to obtain scripts.

Today you are seeing this new doctor with the intention of saying you had acute renal colic last night and that you need oxycodone 5 mg to relieve the pain. You say that the pain was right-sided and was severe enough to have you rolling around in agony. You had kidney stones previously about three years ago and were prescribed oxycodone for your pain. (This started your dependence on opioids, but do not volunteer this information straight away.) You state you had two pills still left in your cupboard from your original presentation. These helped you get through the night, but you now need more. When asked, you have some blood in your urine but no other urinary symptoms. If asked, you are happy for the doctor to contact a GP who saw you for your initial presentation. You state you have been well since and have not needed a regular GP. You are insistent that you need a ‘strong painkiller’ and that paracetamol/ibuprofen will not work.

If the doctor recognises you as a drug seeker, you may start to open up about your background. The initial prescription of oxycodone helped ease your physical pain but also blotted out other pains in your life. You had a difficult childhood and were sometimes beaten and often ignored. You did not achieve well at school and were an angry teen with few close friends.

You have been on various youth schemes but have never had a regular job. You moved to the city so that you could see lots of different doctors to get the oxycodone that you crave.

You have never tried other drugs but have sometimes wondered whether injecting would give you more of a hit than the tablets. You haven’t considered giving up because you can’t see any better way of easing the pain in your life. It is becoming harder and harder to obtain new scripts, and you are open to exploring help.

You have no other relevant ...