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Andrew/Andrea Duncan

 


 
 
CASE SUMMARY:

A. Duncan is a 72-year-old patient who has had low back pain for the last four months. The patient has a history of high blood pressure, kidney disease and colon cancer treated with surgery. S/he seeks to get an idea of where this low back pain might be coming from, as well as what treatment options are available.

Your challenge as the Simulated Patient is threefold:

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

PRESENTATION/EMOTIONAL TONE:

You are 72 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 back pain first started approximately 4 months ago. The pain is a 5/10, constant, dull, and achy. About one month ago, you noticed another kind of pain – a burning, “prickly” feeling that starts in your buttocks, then spreads down both of your legs and feet when you start walking. When this happens, your legs feel crampy, tired, and weak. The leg pain resolves once you stop walking and sit down for a minute. You’ve noticed that when you’re grocery shopping, the back and leg pain is better when you lean forward on the cart for support. At home, you’ve noticed some relief with crouching down or lying in a fetal position (on your sides with your knees tucked up to your chest). For the last few months, you haven’t been able to sleep comfortably on your back.

You can’t recall anything specific that brought it on. Your kidney doctor told you to get the pain evaluated by your primary care doctor, but to try Tylenol in the meantime. For the most part, Tylenol takes the pain down to a 3-4/10, but on bad days it does not seem to work at all.

PAST MEDICAL HISTORY:

If female SP: Breast cancer (diagnosed 11/08), treated surgically
If male SP: Prostate cancer (diagnosed 11/08), treated surgically
Hypertension
Chronic kidney disease Stage III, creatinine 1.6

Surgical History:

If female SP: Left-sided lumpectomy 12/08
If male SP: Prostatectomy, 12/08

Allergies: Penicillin causes a rash

Medications:

Toprol XL 50 mg QD (once a day)
Lisinopril 20 mg QD (once a day)
Fish oil capsules QD (once a day)
Multivitamin with iron QD (once a day)
Colace 50 mg QD (once a day)
Tylenol Extra Strength 500 mg, 1 capsule Q6 hrs PRN pain

FAMILY HISTORY:

Your father died of colon cancer at the age of 69. Your mother had diabetes and was on dialysis towards the end of her life – something you hope never to go through.

SOCIAL HISTORY:

You used to smoke one pack per day for 25 years, but quit 20 years ago. You drink wine with dinner. You used to teach high school English.

REVIEW OF SYSTEMS:

If asked about incontinence, you sometimes lose a little bit of urine now and again. When pressed for details, your reveal that it’s mostly with coughing, sneezing or laughing. You have never experienced any numbness in the genital region. No fevers, chills, night sweats, or unintentional weight loss.

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 are not on the checklist – this is OK.

___________________________________________________________________________________

Andrew/Andrea Duncan

Abnormal Physical Exam Findings

 

The biggest challenge of playing Andrew/Andrea Duncan is mimicking abnormal physical exam findings.

During the physical exam, you will demonstrate:

    • Pain upon bending backward, but not forward. However, you are slow and stiff when bending in all directions and turning from side to side.

 

    • Upon bending backward, you will report worsening pain in your back, as well as some burning and numbness in both legs.
    • You don’t experience any pain during the Straight Leg Raise.

 

When the examiner taps on your knees and behind your feet to elicit your reflexes, mentally attempt to hold your legs and feet absolutely still.