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David/Dana Singer
 


 
 
CASE SUMMARY:

The patient is a 47-year-old who has had low back pain for the last year. The patient has a history of tobacco abuse. 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. Singer’s complaints
  2. Observe the resident’s behavior while you are performing as Mr. or Mrs. Singer; and
  3. Accurately recall the resident’s behavior and accurately complete the performance checklist


PRESENTATION/EMOTIONAL TONE:

You are _47_ (39-49) years old, high school educated 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. Your affect expresses some underlying frustration. You want some relief for your back pain.


Beginning of Encounter:

In response to the question, “What brings you in today,” you say, “This back pain is killing me.”

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. The resident will also perform an exam. During the exam, you should act like you are in some pain – you can even exaggerate this a bit.

The resident will also make some management recommendations. They will likely recommend physical therapy and x-rays. They will want to prescribe you regular doses of an anti-inflammatory medicine, like Naprosyn or ibuprofen, and possibly a muscle relaxant, like Flexeril. If they do, you should “push back” a little – “I already took an over the counter ibuprofen once, and it didn’t work – I really think that Percocet will help me.” The resident should explain why they will not prescribe your Percocet (or another narcotic pain reliever), and you will agree to try it.


HISTORY OF PRESENT ILLNESS/COMPLAINT:

Low back pain has been going on for a year. It is constant, deep, aching and gnawing; pain in the middle of the back is intermittent and sharp. On a good day pain is a 6-7/10, on a bad day 10/10. On bad days you are unable to get out of bed or to do household chores such as cooking, cleaning or yard work. You have missed a few days of work recently because of the pain as well as losing sleep because of the pain. Also, you have had occasional numbness in the lateral aspect of the left thigh. Both legs are painful up to the waist. Legs are weak, and you have had several falls recently. You have used a few of the significant other’s Percocet, which helped a lot.


PAST MEDICAL HISTORY:

Depression
Anxiety

Surgical History:

Tonsillectomy age 11

Allergies: Ibuprofen causes a rash

Medications:

Tylenol – You sometimes take up to 6 at a time, which barely touches the pain.


FAMILY HISTORY:

Mother – diabetes
Father – hypertension, alcoholism


SOCIAL HISTORY:

Occupation – Certified Nursing Assistant at a nursing home
Lives with girlfriend/boyfriend
Smokes 1-2 packs of cigarettes per day since the age of 16
Admits to occasional marijuana use, last use about 3 months ago
Drinks 3 or 4 beers every night.


REVIEW OF SYSTEMS:

If asked about depression, you say not really, except that the pain is starting to make you feel depressed.


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.


RECOMMENDATIONS:

The resident will make management recommendations. These may include x-rays, physical therapy, and medications. The medications will likely be an anti-inflammatory medicine (like naprosyn or ibuprofen), and a muscle relaxant (like flexeril).

 

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David/Dana Singer

Abnormal Physical Exam Findings

 

The biggest challenge of playing David/Dana Singer is mimicking abnormal physical exam findings.


During the physical exam, you will demonstrate:

    • Pain upon bending backward and forward

 

 

 

 

 

 

 

 

 

    • Tenderness all over your back

 

 

 

 

 

 

 

  • Pain in your back, but not down your legs, with Straight Leg Raise