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Mrs. Hassan
 


 
 

Case Focus: Diagnosis and treatment of emotional illness among refugee patients (in this case post-traumatic stress disorder with depression).

Presenting Complaint: Follow-up for complaint of pain in multiple sites.


CASE SUMMARY:

Mrs. Hassan is a 45-year-old Iraqi woman who has been in the U.S. for 8 months. She fled from Iraq to Jordan with 3 of her children after her oldest son had been threatened with death by a rival religious faction. Her husband was killed when a bomb hit his office in Bagdad 12 months before that. One daughter, who is married with a young child, remained behind in Iraq with her family.

Mrs. Hassan has been in to see her primary care doctor and other clinicians at Family Medicine several times since arriving. She has been complaining of pain in different parts of her body, including headaches, backaches and abdominal pain. She has been extensively evaluated with brain MRI and a number of other x-ray and blood tests. Nothing was identified, and she is being treated for mild reflux, tension headaches and mild osteoarthritis.

Mrs. Hassan is back to see the doctor for follow-up of the above. She is still having most of her symptoms. In addition, she is crying almost daily, has no interest in things and has poor appetite, energy and concentration.

She is also experiencing other symptoms that she hasn’t told the doctors about because no one has asked her about these and she didn’t think it was important to bring up. These include terrible nightmares that occur almost nightly about her husband and his death. She didn’t directly witness his death, but had to go to the morgue to identify his body. She finds it difficult to listen to or watch the news – as soon as she hears of bombings or killings in Iraq, she gets very upset and irritable, cannot concentrate and has trouble sleeping. Additionally, although she wanted to stay in direct communication with her daughter in Iraq, these conversations were making her very anxious and jumpy.

Mrs. Hassan was a teacher in Iraq and speaks fluent English.


LEARNER OBJECTIVES:

  1. Conduct a focused interview to evaluate the emotional status of a refugee patient
  2. Be able to diagnose depression and post-traumatic stress disorder
  3. Know how to treat the disorder; and
  4. Identify and address common barriers to treatment of emotional disorders among refugee patients

Your challenge as the Simulated Patient is threefold:

  1. Appropriately and accurately reveal the facts (and emotions) about Mrs. Hassan’s symptoms and medication usage
  2. Observe the resident’s behavior while performing the role; and
  3. Accurately recall the resident’s behavior and complete the performance checklist

Keep in mind that as Mrs. Hassan you don’t understand some of the medical terms for emotional problems, such as “depression,” so if the resident uses such terms, be sure to act unsure and ask what that means.


PRESENTATION/EMOTIONAL TONE

You are respectful to the resident and willing to share your story with the proper prompting/questions from the resident. There are times when you must stop to compose yourself, as it is very difficult to tell the story. At the same time, it is a relief to share your grief and tell someone about it. With gentle probing or encouragement, you resume telling your story.

Beginning of the Encounter:

The resident will ask how you are feeling and you will say:

“I feel about the same as before.”

Throughout the Encounter:

You are taking the pain medication (acetaminophen or Tylenol brand name) and antacid for your stomach (ranitidine). The residents will know that this SP case will be focusing on mental health, and they will know what your current diagnoses are and what medications had been prescribed for you. They won’t know too much about your social history and other symptoms described above or about your experiences, except that you are a widow with 3 children here in Charlottesville. They don’t know how your husband was killed or that your daughter is still in Iraq with her family.


PAST MEDICAL HISTORY:

The pain symptoms as well as emotional symptoms began soon after your husband’s death in Iraq and became worse after coming to the U.S. and being separated from your daughter and her family. Prior to that, you had been in good health. You were hospitalized only for childbirth.


SOCIAL HISTORY:

You are a widow with four children. Your oldest daughter is 26 and lives in Bagdad. The rest of the children live with you in Charlottesville (20 year old son, 15 year old daughter, 12 year old daughter). Your son works doing landscaping, the daughters attend school. You are not working yet due to the various “medical problems” you have. Money is tight and you feel bad that your son has to support the family. You are Muslim.


SUBSTANCE USE:
You do not smoke, drink or use illicit drugs.