Question: You Are Working In A Nearly Empty Small-town Emergency Department In The Middle Of The Night When A Young Woman, A Ms. Harriman, Comes In Holding Her Abdomen And Sobbing. She Is Doubled Over In Pain And Says, “I Think I Have Stomach Or Pancreatic Cancer!” She Moans And Says She Is Nauseated And Says, “I Threw Up Blood At Home! Hematemesis!” You And …

You are working in a nearly empty small-town Emergency Department in the middle of the night when a young woman, a Ms. Harriman, comes in holding her abdomen and sobbing. She is doubled over in pain and says, “I think I have stomach or pancreatic cancer!” She moans and says she is nauseated and says, “I threw up blood at home! Hematemesis!” You and another intern nurse get her into a bed and draw the curtains. You hold a bedpan for her, but she doesn’t vomit. Instead, she says right away, “Is Dr. Collins on tonight? I need to see Dr. Collins. He knows my case. I’m fine alone for a moment. Just please go get him.” You explain to her that you need to check her vital signs first, but she becomes agitated and says, “You’re wasting time! My BP isn’t elevated, my pulse and respirations, all that’s fine. I might be slightly pyretic, but I’m fine. Just please get him. Dr. Collins already knows me. Go!” Just then you are called away by another doctor anyway, so you do leave briefly. As it happens, Dr. Collins is on duty. You don’t relay her special request for him, but you do tell him about her as he comes away from another patient. “Sandi Harriman?” he says. His shoulders slump, and he puts a hand to his forehead. “Not again. How many times—” Then he looks at you. “No, I think it’s better if someone else sees her.” You are slightly puzzled by this, but the other doctor on duty tonight, Doctor Metz, is standing nearby reviewing a chart and looks up and says, “Ah, Ms. Harriman. Yes, I agree. I’ll see her.” Neither of them rushes to her side, however. Suddenly Ms. Harriman makes peculiar, loud retching sounds. You return to her and see thick dark coffee-ground emesis, similar to that seen with serious abdominal disorders, including cancer. You take the pan from her, and the other intern brings her a clean pan and begins the assessment process. A sample of the coffee-ground emesis is sent immediately to the lab. Dr. Metz attends to Ms. Harriman. You are with him during assessment, as she tells him, “I’ve had jaundice, fatigue, weight loss, nausea and vomiting, and back pain. Last time I had a CT scan, but I really think I need an endoscopic ultrasound. Do you think I should have a pancreatic biopsy? Because I’m thinking that’s the only thing that’s going to tell us for sure if I have pancreatic cancer.” Dr. Metz says patiently, “Well, first, we need to pinpoint the location and nature of your abdominal pain. How’s your nausea at the moment? Are you comfortable with me palpating your abdomen?” She nods and lies back, looking at the ceiling. She seems a little relieved. As the sheet is pulled back and the paper gown lifted, you are surprised to see that Ms. Harriman appears to have had at least one other abdominal procedure. Just then, the lab technician motions you out into the hallway. “I need to talk to Dr. Metz. I know he likes to prank, but what are you sending me anyway?” she says. “Is this a joke? Because unlike him, I have actual work to get done.” Just then, the lab technician motions you out into the hallway. “I need to talk to Dr. Metz. I know he likes to prank, but what are you sending me anyway?” she says. “Is this a joke? Because unlike him, have actual work to get done.” “What do you mean?” you say. “What’s the problem?” “This was labeled ‘Coffee ground emesis.'” “Yes, so?” “So. It’s real coffee grounds.” At the same time, your fellow nursing intern comes out of Ms. Harriman’s cubicle and says, “Look what I found under Ms. Harriman’s clothes when I tried to move them.” It’s a kitchen gallon bag with remnants of a brown liquid with what looks like a few last- you guessed it-coffee grounds. 1. What disorder do some of Ms. Harriman’s behaviors most likely indicate? Identify clues that support your temporary diagnosis; include your speculation of what’s going on with those coffee grounds. 1. Why might it be difficult to determine the psychological basis for Ms. Harriman’s somatization? 1. In light of the evidence shown here, what kind of self-assessment may be very important if you will continue to work with Ms. Harriman? Think about your thoughts and feelings about interacting and caring for a client with a somatoform disorder.