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John Harrison
 


 

CASE SUMMARY:

The patient is an 80-year-old man who is slightly hard of hearing. He has hypertension, hyperlipidemia, type 2 diabetes complicated by mild renal insufficiency and peripheral neuropathy, and has also developed mild CHF over the past 10 years. He is coming to see his physician because of two recent falls. One month ago, his doctor increased his Lisinopril from 10-20 mg because his blood pressure was 154/90.

Your challenge as the Simulated Patient is threefold:

  1. Appropriately and accurately reveal facts and findings related to Mr. Harrison’s complaints, ideas, beliefs and expectations
  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 an 80-year-old, middle class Caucasian man. You are casually dressed in trousers, plaid shirt, and wearing a baseball cap. You are well groomed with no visible signs of illness. You appear a little physically fragile with an air of slight anxiety. You are cooperative, but not overly forthcoming with answers and questions. You make frequent eye contact and appear friendly. You are slightly hard of hearing, and once in a while your answer to a question will not make sense because you didn’t hear the question properly.

Beginning of Encounter:

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

First, Well, probably not much, really. It seemed like it was time to come in…and, well, I’m just not feeling as strong as usual – and my balance is off. A couple of times recently I have felt off-balance – and the next thing I know I’m on my way down and am trying to get myself up off the floor.”

The resident will likely follow-up with specific questions regarding your symptoms, underlying medical problems 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 seeing your current doctor at the Family Medicine Clinic for 10 years. You had a general physical exam (including blood work) one month ago. At that time, the doctor told you that your blood pressure was a little elevated and that your diabetes needed some attention, but your kidney function and cholesterol were doing pretty well. S/he sent you for an echocardiogram because of some fatigue and decreased exercise tolerance. It showed mild CHF, but it had not worsened since the last one several years ago. S/he increased your Lisinopril from 10-20 mg and doubled your Glucotrol XL to 10 mg twice daily.

You find that if you have been standing for a long time or get up quickly you feel lightheaded. You also have been finding it difficult to walk with confidence. You have fallen twice, never with any loss of consciousness. You find that you trip more easily and have to concentrate much more on your walking. You feel as if you can’t trust your feet and are having a harder time recovering your balance once you start to fall. You feel better if there is someone walking beside you in case you lose your balance. This bothers you – you have always been self reliant and want to maintain your independence as long as possible. You have always enjoyed your solitary morning walks. They have been an important source of peace for you.

You also get more short of breath on exertion and feel that your energy is generally decreased. About two years ago, you started having a bothersome burning pain in both feet. However, it is only since the Lisinopril was increased that you have had to stop your morning walk.

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

Your wife sets out your medicines and you take them as prescribed, although you are not always sure they are doing anything. Overall, your blood pressure has been good when you are taking all your medications – around 110/80.


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 answer what you thought you heard).

You have always tended to downplay your symptoms, but you are frustrated with your tendency to feel off balance. (“I feel like an old man, staggering along.)

Your wife always sets out your pills, so you don’t know all the names and doses. (“There used to be 6, but now there are 7 – 1 for blood pressure and 3 for diabetes in the morning and 1 for cholesterol and now 1 for diabetes at bedtime. And the water pill– and the blood pressure medicine got increased last time I was in.)
If the resident says something like: “Tell me about your feeling of being off balance.” you would respond with…

“When I get up suddenly, I feel like I might faint – like I need to sit down. And when I am walking, at times I just don’t seem to have very good balance. A few times, when I have gotten up too quickly, I have lost my balance and fallen.”

If the resident asks “Does the room feel like it is spinning around you?” you answer “No.

If the resident asks “Have you ever hurt yourself when you have fallen? Hit your head?” you answer No.

If the resident asks “Do you remember falling? Do you think you have ever lost consciousness with your falls?” you answer “No, I have not lost consciousness.”

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

“I am a little more tired than I would like to be.”

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

“I did get short winded when I was walking in here from the parking garage – but no chest pain.”

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 asks you about any other changes in your medications, over-the-counter medications or supplements, you would respond with: “I just take what I am prescribed – that’s enough pills!”

If the resident asks something about your beliefs, ideas, feelings, or expectations about what is going on with you, you would respond with:

“I think it is important to take the medication that you give me – I know it is important to prevent more problems. But it just seems to be giving me more problems now. I am really worried about falling, and I really enjoy walking – I have always done it, and I want to keep doing it as long as I can.”


PAST MEDICAL HISTORY:

(The resident will also have this information to review prior to the encounter)

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 walk around the neighborhood in the morning. You both go for a walk in your neighborhood after dinner most nights. You keep your regular appointments with your doctor. You have had two 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 (>20 years) thought to be due to working around loud farm equipment
Hypertension (30 years)
Hyperlipidemia (17 years)
Type 2 Diabetes Mellitus (15 years) with retinopathy
Chronic kidney disease (12 years)
Pneumonia 2004
CHF with EF 40% on echo 2009

Hospitalizations:

Pneumonia 2004
Inguinal hernia repair 1990

Medications:

Lisinopril 20 mg daily
Metformin SR 1000 mg 2 tabs daily
Glipizide XL 10 mg twice daily
Lipitor 10 mg daily
Lasix 20 mg daily
Baby Aspirin daily


SEXUAL HISTORY:

You have been in a monogamous relationship with your wife for 55 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 15 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 84 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 78 and 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.


FEELINGS, IDEAS AND EXPECTATIONS ABOUT YOUR HEALTH:

It is important for you to remain independent. You believe it is important to take medication as prescribed to prevent disease complications, but you are not sure it is worth it if it affects your ability to function as you would like. You are willing to discuss the pros and cons of this with the physician, but if forced to choose, you think it is very important for your personal well-being to continue your morning walks for as long as you can.


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, assessing your balance and gait and assessing sensation in your feet (Refer to the “Standardized Patient Checklist” and the “Guide to the Checklist” for details).

Your reflexes are normal at your knees, but decreased in at your ankles.

Your feet and lower extremities are numb to pinprick and light touch (you can’t tell the difference) about half way to your knees and you do not have vibration sense in your feet or ankles. You do have vibration sense at the knee.

When the resident asks for you to arise from the chair, you have to use your hands to push up from the chair and you will waver a bit when you first stand up. After about 10 seconds, you will stand without wavering. When you sit down, you have to use your hands to guide yourself down softly or you “plop” from several inches away from the seat cushion – your hip muscles are too weak to guide you gently into the chair.

When the resident assesses your gait, you will have a slightly wide-based gait and will step carefully, but will not stagger or fall. When the resident assesses your balance, you sway a little, but don’t fall or stagger. You do keep your feet shoulder-width apart.