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Michael/Michelle Thomas
 


 
 
CASE SUMMARY:

The patient is a 68-year-old man or woman who has had low back pain for the last four months. The patient is otherwise healthy, and seeks to get an idea of where this low back pain might be coming from, as well as what could be done for it.

Your challenge as the Simulated Patient is threefold:

  1. Appropriately and accurately reveal facts and findings related to Mr. or Mrs. Thomas’s complaints
  2. Observe the resident’s behavior while you are performing as Mr. or Mrs. Thomas; and
  3. Accurately recall the resident’s behavior and accurately complete the performance checklist.


PRESENTATION/EMOTIONAL TONE:

You are 68 years old, college-educated, retired, and otherwise healthy. You are well groomed and dressed in your underclothing covered by a hospital gown, which is open to the back. You are cooperative, but not overly forthcoming with answers and questions. You make frequent eye contact and appear friendly.

Beginning of Encounter:

In response to the question, “What brings you in today,” you say, “My back has been bothering me for the last four months.”

The resident will likely follow-up with specific questions regarding your back pain, other symptoms and medications. These questions should be answered with simple responses to the direct questions. You should not offer information unless directly questioned by the resident.


HISTORY OF PRESENT ILLNESS/COMPLAINT:

Your pain first started approximately 4 months ago. You can’t recall anything specific that brought it on, but you had gone to visit your daughter and grandchildren several days before (ages 1 and 3 years, if asked). It gradually started over a few days, on and off, but pain now occurs almost every day. It lasts for several hours at a time. Currently you would rate it as a 5/10. You used to do aerobics several times a week, but now are unable to do so because bending over worsens the pain. The pain is worse with coughing and sneezing, sitting for a long time in the car or at the computer, and bending over to do laundry. You get some relief after taking one or two tabs of Advil. Also, you have been experiencing some intermittent shooting pain down the back of the right leg as well. This, too, has been getting worse.


PAST MEDICAL HISTORY:

You have no other medical problems – “Lucky me.”
You have never had surgery
No allergies that you’re aware of
You take one multivitamin daily – Centrum Silver.


FAMILY HISTORY
:

Your father died at the age of 98 from “old age.” Your mother, age 90, is still alive – “Good genes, I guess.”


SOCIAL HISTORY:

You are happily married, and have lived with spouse of 30 years. You retired 2 years ago and are enjoying your retirement. Prior to that, you worked as an engineer for an auto company. You have one daughter who lives in northern Virginia, and you enjoy visiting with her and your grandkids on the weekends. You try to eat right and stay active by going to the gym three times a week. Hobbies include traveling and photography.


SUBSTANCE USE:

You’ve never smoked, and rarely drink alcohol (you have champagne on New Year’s Eve and on your anniversary).


REVIEW OF SYSTEMS
:

If asked, you have never accidentally lost control of your urine or your stool. You have never experienced any numbness in the genital region, or any weakness in your legs that you’re aware of.


PHYSICAL EXAMINATION:

Residents will perform a physical examination. This may include listening to your heart and lungs with a stethoscope, but may only involve an examination of your back, as well as an examination of your legs and feet. The resident may examine your back or legs in ways that aren’t on the checklist – this is OK.

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Michael/Michelle Thomas

Abnormal Physical Exam Findings

 

 

The biggest challenge of playing Michael/Michelle Thomas is mimicking abnormal physical exam findings.

During the physical exam, you will demonstrate:

    • Pain upon bending forward, but not backward. However, you are slow and stiff when bending in all directions and turning from side to side.
    • Upon bending forward, you will report pain shooting down the back, as well as the outside, of your right leg.
    • You will report this same pain during the Straight Leg Raise.

  • When the examiner taps on your low back, jump as though uncomfortable.
  • When the examiner taps behind your feet to elicit your ankle reflexes, mentally attempt to hold your right foot absolutely still.

    • When the examiner is asking whether you can feel his/her touch on the back of your right leg, outside of your right leg, and the top of your right foot, you will say that it feels “kind of numb” – but you can feel it when he/she touches your other leg and foot just fine. See the “L5” and “S1” patterns shown below – that’s where you are numb.

    • If the examiner asks you to point your right big toe upwards (towards your nose), you will be unable to do this. Likewise, if the examiner asks you to point your foot towards to the floor (like a ballet dancer would point), or to “step on the gas” against resistance – you can do this, but only weakly.
    • When asked to walk on your toes or heels, you can do it with your left side, but your right foot will tend to stay flat on the floor.