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Training Materials

John Harrison

SP Training Materials^

 

CASE SUMMARY: 

The patient is a 70-year-old man who is slightly hard of hearing and has hypertension, hyperlipidemia, Type 2 diabetes, and mild chronic kidney disease.  He is coming to see his new family physician for regular follow up of his diabetes and hypertension.  He has also had some pain in his feet recently.
Your challenge as the Simulated Patient is threefold:

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


PRESENTATION/EMOTIONAL TONE:

You are a 70-year-old middle class Caucasian man. You are casually dressed in trousers, plaid shirt, and wearing a John Deere hat. You are well groomed and appear healthy with no visible signs of illness. You are cooperative, but not overly forthcoming with answers and questions.  You make frequent eye contact and appear friendly. Because you are hard of hearing, you will intermittently need to interject, “Excuse me?”  “Could you say that again?”, “What was that again?” or place your hand to your ear until the resident recognizes and accommodates your hearing impairment.

Beginning of Encounter:

In response the question, “What brings you in today,” you answer in exactly the following words:

First, “Excuse me? – I’m afraid I’m a bit hard of hearing.”

And then, “Well, I guess this is my regular check up for the diabetes…but my feet have been bothering me at times, too.”

The resident will likely follow-up with specific questions regarding your foot pain, diabetes, 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:

You have been a patient of the Family Medicine Clinic for 20 years. Your previous doctor finished his residency 3 months ago and referred you to the doctor you are seeing today (the resident examiner is your new Family Physician). Your last visit was 6 months ago. At that time, you had a general physical exam (including blood work). The doctor told you that your diabetes, blood pressure, kidney function, and cholesterol were doing pretty well and that you should continue to work on a healthy diet and to get some exercise.

You have had some bilateral foot pain that you notice mostly at night. It has gotten better with Ibuprofen (2-3 tabs). You think the pain is worse after you have been on your feet a lot, but you are not sure.

You have longstanding decreased hearing in both ears but have not felt it necessary to be fitted for hearing aids yet.

General Questions:

You have difficulty hearing and if you do not hear the resident clearly, you should say something like (“Excuse me?” or “I didn’t quite get that” or “Could you say that again, please?” or just look at the doctor questioningly).

You tend to downplay your symptoms (“I suppose you get these things as you get a little older).

Your wife always sets out your pills, so you don’t know all the names and doses. (“There are 6 all together – 2 for blood pressure and 3 for diabetes in the morning, and 1 for cholesterol at bedtime).

If the resident says something like:  “Tell me about your foot pain.” you would respond with…

“Well, it is nothing much really – just some sort of numbness and tingling.  A couple of Advil takes care of it – and it doesn’t really stop me from doing my things.”

If the resident says something like:  “How are you feeling overall?” you would respond with…

“Can’t complain.”

 If the resident says something like:  “Do you have any chest pain or shortness of breath?” you would respond with…

“No, sure haven’t.”

If the resident says something like:  “Are you taking your medicines?” you would respond with…

“ Oh yes – my wife makes sure of it.”

If the resident says something like:  “Have you noticed any change with your vision?” you would respond with…

“ Well, I’m sure I don’t see as well as I used to – but I can still read the newspaper.”


PAST MEDICAL HISTORY:

Overall Health:

You feel that your health is pretty good despite having to take a few medications. Your wife tries to make you eat a healthy diet. You both go for a walk in your neighborhood after dinner most nights. You keep your regular appointments with your doctor. You have had 2 normal colonoscopies in the past. You see the Ophthalmologist every year. You have had your Pneumovax (at age 65) and got a flu shot in October. You get a flu shot every year. You have also had a Zostavax immunization.

Prior Illnesses:

Bilateral hearing impairment (>10 years) thought to be due to working around loud farm equipment
Hypertension (20 years)
Hyperlipidemia (7 years)
Type 2 Diabetes Mellitus (5 years)
Chronic kidney disease (2 years)
Pneumonia 2004

Hospitalizations:

Pneumonia 2004
Inguinal hernia repair 1990

Medications:

Lisinopril 10 mg daily
HCTZ 25 mg daily
Metformin SR 1000 mg 2 tabs daily
Glipizide XL 10 mg daily
Lipitor 10 mg daily
Baby Aspirin daily


SEXUAL HISTORY
:

You have been in a monogamous relationship with your wife for 45 years.


LIFESTYLE/HABITS:

Diet and Exercise:

Generally, a balanced meat, potato and vegetable diet. Your wife has been baking rather than frying meat and serving more vegetables since you got diabetes. You eat mostly chicken and fish. You do like pie – and gravy on your potatoes when you get the chance.

Alcohol: A beer now and then, about 3 per week

Smoking: None for the past 5 years, smoked 1 pack/day for 45 years before that

Caffeine: You drink 1 cup of regular coffee in the morning.

Hobbies/Interests: Add personal experiences here

Education: You completed high school at age 18. You have no formal degree beyond high school.

Occupation: You grew up on a farm.  You worked as a sales clerk at a hardware store after high school and started farming on your own at age 25.

Living Situation: You live with your wife. You still drive. You live in a one floor bungalow in a safe neighborhood and have a small yard with a garden.


FAMILY HISTORY
:

Mother: Your mother died at the age of 82 of “heart problems.”

Father: Your father died at the age of 83 of lung cancer. He was a heavy smoker most of his life.  You had a good relationship with both parents.

Siblings: You have one brother who is 74 and has blood pressure and cholesterol. He had surgery for colon cancer 2 years ago and is doing well. He lives in Pennsylvania. You have one sister (Martha) who, you think, is relatively healthy. She is 68 and lives also lives in Pennsylvania. You are not very close and see each other rarely.

Children: You have two sons (Steven and Mark) and 5 grandchildren. Mark lives in North Carolina and calls every 2-3 weeks. Steven lives 1 hour away and you see him and his family (3 children) about once a month. You are close to your children and feel you could call them (especially Steven) if you needed something. Both Steven and Mark and their families were home for Christmas.


PERSONAL HISTORY:

You grew up in a middle class farming family in Pennsylvania. You met your wife while working as a clerk in a hardware store as a young man. You married and moved to Virginia where your wife’s family lived. You had a cash crop farm for 40 years and moved from the farm to a small house in Charlottesville after you retired.

You made a reasonable living farming, although there were certainly some difficult years. You are quiet by personality, but have been well respected by your community. You like to tinker at odd jobs, fixing small motors and generally just staying busy. You are an elder at your church and attend regularly. You have been satisfied with your home life and are enjoying retirement.

Your wife has always been the homemaker, and she does all the cooking, manages your medications and doctor appointments, and also has the most regular contact with your children.  She has arthritis in her knees and hips and high blood pressure, but generally manages very well. You rely considerably on your wife.


PHYSICAL EXAMINATION:

Residents will likely perform an examination. This may include looking in your eyes with an ophthalmoscope, listening to your heart and lungs with a stethoscope, testing your reflexes with a reflex hammer, looking at your feet, assessing sensation in your feet, and checking the pulses in your feet. (Refer to the “Standardized Patient Checklist” for details).

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Open Resident
Instructions

CLINICAL PERFORMANCE EXAMINATION (CPX)

Resident Instructions^

 

Station Length:       15 minutes maximum

Patient Name:      John Harrison

Resident Instructions:

John Harrison is a 70 years old man with hypertension, hyperlipidemia, type 2 diabetes, and mild renal failure. He is coming to see you for regular follow-up of his diabetes and hypertension. He does not take insulin and has been told that he does not need to check his blood sugar. Lately, he has also had some pain in his feet.

His previous resident doctor graduated, and you will now be his family physician. This is a routine follow-up visit, and he is scheduled for a complete physical exam with you in a few months.

On his last visit 6 months ago:  Weight was 91kg which was stable, blood pressure was 135/80, HgA1C 7.0, tchol 174, tg 130, hdl-chol 35, ldl-chol 129, creat 1.4 and rest of comp chem and cbc normal.

He smoked for many years, but quit 5 years ago, and has not smoked since.

He has had 2 normal colonoscopies in the past – the last 2 years ago.

He has had a flu shot this year, and a Pneumovax 5 years ago.

Today his weight is 91.5kg and BP 140/80, RR18, HR 72, temp 37.1. Foot pain: 1/10.

Medications:

Lisinopril 10mg daily
HCTZ 25 mg daily
Metformin SR 1000mg 2 tabs daily
Glipizide XL 10mg daily
Lipitor 10 mg daily
Baby Aspirin daily


Once you have obtained a focused history and exam, you are to leave the room and complete the checklist on the computer.

 

PLEASE DO NOT WRITE ON THIS PAGE

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Open Patient Chart

Patient Chart^

 

Temp   37.1                      BP       140/80           HR      72                

Patient Name    John  Harrison        Patient Age           70     

History Number  022557                            Chart Number             086254       

RR       18                    HT                               WT      91.5 Kg        

Smoking: No 

Complaint:      follow up of diabetes and hypertension, and foot pain     

Nurse’s signature        Diane Walters                          

Copied                                    Dictated

 

Reviewed w/attending    

 

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Open SP Checklist

John Harrison 70 y.o.

Standardized Patient Checklist^

 

Your Name ______________________ Resident Name_____________________


GLOBAL RATING

  1. John Harrison was satisfied with this resident encounter.    YES        NO

Your response to this item should be as “John Harrison” would respond – NOT as you, the standardized patient, would respond, knowing what the resident is being tested on in the checklist.

YES

  • You feel you would come back to this resident for the rest of your care.
  • You feel this resident was helpful OR will be able to help you (in your total care).

NO

  • You feel anything in the encounter with the resident would negatively impact Mr. Harrison significantly enough to cause him to consider seeing someone else for his care.

Your response on this item might not add up to the responses you will make on all of the other items on the checklist. That is fine. This item is included so that you can make a global assessment based on your own feelings about the encounter.

In addition, please keep in mind that these are residents who are still in training, NOT seasoned physicians. You should not be comparing their performance to your previous experiences with practicing physicians.

HISTORY

***General principle in dealing with MULTIPLE QUESTIONS buried in a single resident question:

Example:  Do you drink alcohol or do you do any drugs?

  • Answer only the LAST question asked
  • Give credit on the checklist for ONLY the questions you answer

Use the following guide to answer:

  1. The resident asked about chest pain, OR shortness of breath, OR new fatigue. (“No.” to any or all of these)

DONE             NOT DONE

  1. The resident asked about whether I am taking my medications regularly. (“I expect so – My wife sees to it.”)

DONE             NOT DONE

  1. The resident asked whether any of my medications bother me. (“No – no real problem.”)

DONE             NOT DONE

  1. The resident asked about my foot pain. (“Oh, it is not really anything – just some kind of burning pain that comes and goes.”)

DONE             NOT DONE

  1. The resident asked me to describe the “quality” of the pain. “What does it feel like?” (“I suppose it is like a kind of burning.”)

DONE             NOT DONE

  1. The resident asked me to describe the “severity” of the pain on a scale of 1-10, or mild, moderate or severe. (“1-2” or “mild.”)

DONE             NOT DONE

  1. The resident asked me if anything makes the pain better or worse. (“It might be a bit worse after I have been on my feet a lot. 2-3 Advil does help the pain.”)

DONE             NOT DONE

  1. The resident inquired about my current hobbies or what my typical day is like. (“I guess my wife would say I putter. I get up, have breakfast and then head out to the shed. There are always things that need fixing. I tend the lawn and the vegetable garden. My wife does the flowers. I read the paper and usually have a rest sometime in the afternoon. Sometimes I meet one of my friends for coffee.”)

DONE             NOT DONE

  1. The resident asked about support systems. (“My wife and neighbors from church. Also, my son in Virginia.”)

DONE             NOT DONE

  1. The resident asked about symptoms of low or high blood sugar (shakiness, cold sweats, confusion, lightheadedness for the former, or feeling very thirsty, frequent urination, or increased appetite). (“No trouble with that.”)

DONE             NOT DONE

  1. The resident asked about orthostatic dizziness (feeling like you are going to faint upon standing). (“Maybe if I get overheated working in the garden, but not too often.”)

DONE             NOT DONE

  1. The resident asked about trouble with balance or gait. (“No.”)

DONE             NOT DONE

PHYSICAL EXAMINATION

  1. The resident looked in my eyes with the ophthalmoscope.

DONE             NOT DONE

  1. The resident listened to my heart.

DONE CORRECTLY      DONE INCORRECTLY     NOT DONE

DONE CORRECTLY: The resident listened to my heart in 4 places AND listened under (not through) clothing.

DONE INCORRECTLY: The resident listened to fewer than 4 places OR listened through clothing.

  1. The resident listened to my lungs.

DONE CORRECTLY      DONE INCORRECTLY     NOT DONE

DONE CORRECTLY: The resident listened to my back under (not through) my clothing.

DONE INCORRECTLY: The resident listened to my back with stethoscope through clothing.

  1. The resident looked at my feet.

DONE CORRECTLY      DONE INCORRECTLY     NOT DONE

DONE CORRECTLY: The resident looked at my bare feet AND checked between my toes and on soles.

DONE INCORRECTLY: The resident looked at my feet with socks OR did not check between my toes.

  1. The resident felt pulses on the tops of my feet and near my heel.

DONE             NOT DONE

  1. The resident checked the sensation of my feet with a microfilament.

DONE             NOT DONE

PATIENT-PHYSICIAN INTERACTION

  1. The resident accommodated my hearing difficulty.

DONE CORRECTLY      DONE INCORRECTLY     NOT DONE

DONE CORRECTLY: The resident recognized your hearing difficulty and adapted by speaking more slowly, in a lower pitch, slightly louder and by directly facing you when speaking AND confirmed that you were able to hear or comprehend with these changes OR the resident offered you his/her stethoscope and spoke into the bell AND confirmed that you were able to hear.

DONE INCORRECTLY: The resident spoke louder or made accommodations for your hearing difficulty, but did not confirm that you could hear with his/her adjustments.

NOT DONE: The resident did not recognize hearing difficulty OR the resident recognized but did not make accommodation for hearing difficulty.