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___________________________________________________________________________________

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John Harrison

SP Training Materials^

 

CASE SUMMARY

The patient is an 88-year-old man with hypertension (high blood pressure), hyperlipidemia (high cholesterol), CHF (congestive heart failure), type 2 diabetes complicated by chronic kidney disease, stage 3, (chronic kidney damage) peripheral neuropathy (damage to nerves in lower extremities) and retinopathy (damage to retina from diabetes). He also has age-related (dry) macular degeneration and has had cataracts removed from both eyes. You have seen him in the past because of falls which still happen occasionally, but less often since he started using a cane.  His son sent you letter a few weeks ago expressing his concern about his father’s safety while driving. Mr. Harrison’s wife passed away 2 years ago. She used to do most of the driving, and now he is driving himself. Last month he had a minor accident scraping the car next to him in a parking lot, and the neighbors have told the son that they have seen Mr. Harrison driving very slowly down the middle of the road. He is here to follow up on his hypertension and diabetes, which have been well controlled. You plan to use this opportunity to talk with him about his driving safety.

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 an 88-year-old middle class Caucasian man. You are casually dressed in trousers, plaid shirt, and running shoes. You are reasonably groomed, but shirt is not properly tucked in and has some spots from spilled food on it. You appear physically fragile and with an air of mild anxiety.  You are cooperative, but not overly forthcoming with answers and questions. You make eye contact with your doctor. You are 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. You aren’t anxious to stand up and walk as you are off balance and need a cane to walk.

Beginning of Encounter:

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

First, Just to check on the blood pressure I guess.” 

The resident will likely follow-up with specific questions regarding your symptoms, underlying medical problems and medications.  The resident will also talk with you about whether or not you should be driving.  Answer direct questions with simple responses. 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 20 years.  Your health has been relatively stable with some decline in your balance and vision. You have diabetes, HTN, CHF, and hyperlipidemia, all of which are under reasonable control. Your medications have not been changed for over a year.

Two years ago, your wife (Marion) passed away unexpectedly. You have been very lonely since, although Steven, your son who lives nearby, comes by about once a week and helps you with your groceries. Steven also fills your pill box. Your doctor started you on an antidepressant shortly after Marion passed away. Marion always set your pills out, made your meals, arranged your doctor’s appointments, and did most of the driving.

You spend most of the day in the house because of your fear of falling while walking. You used to read the local paper daily, but your vision now makes that difficult. You are hard of hearing, and although you can still talk on the phone, it is difficult to hear. You watch a lot of TV and care for your small dog, Champ.

Steven has been after you to give up driving. He thinks you should move into an apartment complex for senior citizens. He told you he was going to write to your doctor about his concern about your driving. Although you appreciate his help with a lot of things, you feel he is overstepping his boundary on this issue and that he shouldn’t get involved.

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.).

Your son sets out your pills and you don’t know all the names and doses. You do take all your medications and don’t have any problems with side effects. (“There are 8 – 2 for blood pressure, 3 for diabetes, and one for depression in the morning, and 1 for diabetes and 1 for cholesterol in the evening.).

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

“I suppose fine for my age. My hearing is going, and it is hard to read.  I need a nap every afternoon – and I have to be really careful not to fall.”

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

“A little short of breath, but – but no chest pain.  Nothing new.”

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

“ Yes. My son sets them out for me.”

If the resident says something like; “I got a note from your son, Steven. He is worried about your safety driving.” you respond with…

“Steven has always been overprotective.  I don’t drive unless I need to and I never drive at night. I think I do pretty well.”

If the resident asks: “When was the last time you took a driving test?” you answer…

“I suppose it has been a few years – but I did fine then, and I drive fine now. Better than a lot of young people on the road, I’d say. If I was worried, I would go have a test.”

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

“It doesn’t suit me to be reliant on people so much. My son is good to me, but sometimes I just want to live my life. I am afraid Steven is going to try to get me to move – into one of those seniors’ homes. But this is my home – this is where Marion and I started our life and raised our children. And I need to be able to drive to get my groceries and the things I need.”


PAST MEDICAL HISTORY:

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

Overall Health:

You feel that your health has been declining over the past few years. Your wife died, unexpectedly 2 years ago and you have been lonely without her. You used to walk every night, but now you are unsteady on your feet and don’t walk for fear of falling. You know your neighbors, but really don’t see people anymore. Your wife was the one who kept you socially connected. You have 2 sons – one (Steven) who lives in Richmond and comes by a lot to check on you. Your hearing and vision have deteriorated and this has further isolated you. You are up to date on your preventive care and want to get a flu shot today and the swine flu shot if it is available.

Prior Illnesses:

Bilateral hearing impairment (>30 years) thought to be due to working around loud farm equipment
Hypertension (38 years)
Hyperlipidemia (25 years)
Type 2 Diabetes Mellitus (23 years) with retinopathy
Chronic kidney disease, stage 3 (20 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 were only in a monogamous relationship with your wife of 63 years. She has since died.

LIFESTYLE/HABITS:

Diet and Exercise:

You don’t eat as well since your wife died. You like meat and bread, but don’t get many fresh vegetables. Sometimes Steven’s wife sends a good stew.

Alcohol:

A beer now and then.  About 2-3 per week.

Smoking:

None for the past 23 years. Smoked 1 pack/day for 45 years before that.

Caffeine:

You drink 1cup of regular coffee in the morning.

Hobbies/Interests:

Add personal experiences here. You also enjoy your dog, Champ. You and your wife got him from the pound the year before she died, and Champ seems like a connection to her.

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 alone. 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 92 and has blood pressure and cholesterol.  He had surgery for colon cancer 10 years ago and is doing well. He lives in Pennsylvania. You have one sister (Martha) who, you think, is relatively healthy. She is 86 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 he comes by to check on you every week or so. He fills your pill box and sometimes takes you grocery shopping. You are close to your children and feel you could call them (especially Steven) if you needed something. You have been upset with Steven for suggesting you give up driving and that you should move to an old age home.


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 was always the homemaker and she did all the cooking, managed your medications and doctor appointments. She died 2 years ago. Your son, Steven, has been in close contact since his mother’s death, but it is hard for him driving back and forth from Richmond so often. You don’t really have anyone to call here if you ran into trouble. Marion was the one who kept up your social contacts.


FEELINGS, IDEAS AND EXPECTATIONS ABOUT YOUR HEALTH:

Your independence has always been important to you. You are frustrated because your poor balance means you can’t go for the walks, which you have always valued. Also your hearing and vision are both worsening. You are afraid that if you are not able to drive, you will not be able to live on your own. You are worried that if you are made to move into an apartment or old people’s home that you will have to give your dog, Champ, away. You need to be able to drive to get your groceries and other needs. You are conflicted in your relationship with your son, Steven. You appreciate his help, but you resent the fact that he thinks you should not drive and should live in a retirement facility. If Marion were still alive, this wouldn’t be an issue. She did most of the driving. You have a good relationship with your doctor, but are afraid that he will side with Steven.


PHYSICAL EXAMINATION:

Residents may or may not perform an examination. (Refer to the “Standardized Patient Checklist” for details.) Your exam has not changed since last visit.

Your vision with the Snellen chart is 20/80 (right) and 20/100 (left) with your glasses on.

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 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 rise 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.

If the resident assesses your visual fields, respond using your own visual fields.

If the resident assesses the range of motion of your neck and/or upper extremities, use your own range of motion.

 

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Open Resident
Instructions

CLINICAL PERFORMANCE EXAMINATION (CPX)

Resident Instructions^

 

Station Length:          22 minutes maximum

Patient Name:            John Harrison

Resident Instructions:

John Harrison is an 88-year-old man with hypertension, hyperlipidemia, type 2 diabetes, stage III chronic kidney disease, mild CHF and dry macular degeneration (not the bad kind). He saw you 3 months ago for follow-up of his medical problems, and all were stable. You did not change any of his medications.

You received a letter from Mr. Harrison’s son in Richmond noting his concern for his father’s driving. (See attached)

Mr. Harrison is here today for follow up of his blood pressure, but you think it is more important to talk with him about whether or not he should be driving.

Today his weight is 91.3kg and BP 120/80, RR18, HR 72, temp 37.1, Vision is 20/80 OD, and 20/100 OS 

You review the patient’s last note which reveals the following:

7/10/09

Reason for visit:          Follow up HTN, DM, CRF, CHF, Hyperlipidemia

PMHX:

Bilateral hearing impairment (>30 years)
Hypertension (38 years)
Hyperlipidemia (25 years)
Type 2 Diabetes Mellitus (23 years) with retinopathy
Chronic kidney disease (20 years)
CHF with EF 40% on echo 2009

Past 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

Social Hx:

Retired farmer
Widowed 2 years ago
Lives alone – 2 sons involved
Lives in 1 floor bungalow
Etoh – 3 beer/wk
Tobacco – 45 pack years. Quit 23 yrs ago

Family Hx:

m.d. 82 – ‘heart problems”
f. d. 83 – lung ca, smoker
brother. 92 – htn, lipids, colon cancer – doing well
sister. 86 – healthy
2 sons, 5 grandchildren all healthy

Preventive health:

Colonoscopy normal x3 (last 2005)
See ophthalmologist yearly
Pneumovax at age 65
Flu shot yearly

ROS:

fatigue, decreased exercise tolerance
No chest pain, SOB, cough, leg swelling, weakness.  No focal symptoms. Denies depression.

PE:

Elderly man NAD. BP 128/62. HR 76. RR 16. T 36.4. Vision 20/80 OD, 20/100 OS

HEENT: PERLA, EOM normal, OP normal, TM normal. No carotid bruit. No LAD.  Thyroid normal

Chest: Clear

CVS: RRR no RMG

Abd: Normal. No mass or HSM

Extrem: No edema. Decreased sensation to protective sensation using the monofilament. Good pulses. Good cap refill.  No skin breakdown.

Skin: Multiple seb Ks. Few cherry angioma. No suspicious lesions.

Assessment:

  1. HTN, DM, CRF, CHF, hyperlipidemia stable on current meds
  2. Colon ca screening UTD, pneumovax and flu shot UTD, takes baby Aspirin

Plan:

  1. Zostavax
  2. Chemistry, cbc, HgA1c, lipid profile
  3. f/u blood pressure 6 months

You also have a note sent by patient’s son (see attached)

 

Once you have obtained a focused history (with or without exam) and discuss your management recommendations with the patient, you are to leave the room and complete a checklist on the computer.

 

 

 PLEASE DO NOT WRITE ON THIS PAGE

 

___________________________________________________________________________________

Oct 2 2010

 

Dear Doctor,

 

Thank you for your care of my father, John Harrison, over all these years. He has an appointment with you in the next few weeks and I hope you will talk with him about his driving. As you know, Dad turned 88 last month and my brother and I are worried about his safety. He has a hard enough time just with his balance, let alone getting behind the wheel. His car has a lot of scrapes on it, which he says must be from people running into his car in parking lots. One of the neighbors told us that they have seen him driving slowly in the middle of the road, and I know that he had a fender bender in the parking lot at the grocery store a couple of weeks ago that his insurance is going to pay on.

We know he is worried about losing his independence, but are concerned for his safety and the safety of others. Would you talk with him? Is there anything else we should do besides take his keys?

Thank you for your help.

Sincerely,

 

Steven A. Harrison

 

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Open Patient
Chart

Patient Chart^

 

 

Temp   37.1                      BP       120/80          HR      72                 

Patient Name    John  Harrison                     Patient Age                 88     

History Number  022557                            Chart Number             086254       

RR       18                    HT                               WT      91.3 Kg        

Complaint:      follow-up of his blood pressure                                   

Nurse’s signature        Diane Walters                          

Copied                                    Dictated

 

 

Vision Right Eye 20/80

Vision Left Eye 20/100

(with glasses on)

 

 

Reviewed w/attending

 

___________________________________________________________________________________

Open SP
Checklist

John Harrison 88 y.o.

Standardized Patient Checklist^

 

Your Name ______________________ Resident Name _____________________

 

GLOBAL RATING

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

COMMENTS:

 

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 physician for the rest of your care.
  • You feel this resident was helpful OR will be able to help you (in your total care).
  • You feel that the resident tried to understand your beliefs and expectations about driving and living independently.

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.
  • You feel that the resident made recommendations, but did not try to listen to your thoughts and ideas about driving and living independently

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 resident physicians 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 student 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.

Please record how the resident elicited the following information:

  1. The resident asked about general well being and recent health. (“I suppose fine for my age. My hearing is going, and it is hard to read. I need a nap every afternoon – and I have to be really careful not to fall.”)

DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:        The resident asked something like:  “How have you been feeling lately?”

DONE INCORRECTLY:   The resident used a closed ended question such as “So, you are doing fine, are you?” or s/he asked how you were but did not give you time to answer.

  1. The resident asked about visual changes (“I see the eye doctor regularly – and those 2 cataracts taken off.  I’m sure I don’t see as well as I used to.”)

DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:        The resident asked if you have had any changes in your vision, or “How your vision is now?”

DONE INCORRECTLY:   The resident asked only if you were seeing an eye doctor.

  1. The resident asked about my beliefs, ideas, feelings or expectations about my independence. (“It is important for me to remain independent. If I stop driving, I can’t live on my own.  I will stop driving when I think I am not safe anymore. I think my son should not have contacted you.”)

DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:        The resident asked you how you felt about driving or if you had any concerns about your driving or shared your son’s concerns about your driving and asked you what your thoughts were about that.

DONE INCORRECTLY:   The resident confronted you about your driving, e.g. “It is not safe for you to drive, and you should stop.” This could also be a matter of tone – were the questions asked in a spirit of exploration or judgment?

  1. The resident asked about the amount of support I have available in my home. (“Marion was really the person who kept us connected to folks, you know? My son comes every week, and he calls about every day. I know my neighbors, but I don’t see ‘em much – I don’t get out much. It’s hard for me to talk on the phone, so I don’t do that much anymore. My dog Champ keeps me company though – he’s a good dog.”)

DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:        The resident asked about help or support you had available in your neighborhood or home.

DONE INCORRECTLY:   The resident only asked about whether your son’s visits.

  1. The learner asked me how not driving would affect my ability to live alone. (“I need to drive to get my groceries, pay some bills, and go to church. I can’t be relying on people all the time to take care of me.”)

DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:        The resident asked you about the relationship between driving and living alone, or how not driving would affect you.

DONE INCORRECTLY:   The resident only asked about the places you went when you drove.

  1. The resident asked about your goals related to driving – is it more important that you drive so you can get out and do things or more important that you drive so that it helps you live independently in your home. (“I guess I never thought about it. It’s not like I enjoy driving anymore – I really have to be very careful, and I worry about getting in an accident. I don’t think I can stay in my house if I can’t drive, so I think it’s more important to me as a way for me to stay in my house.”)

DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:        The resident asked you to examine, in some way, what was important to you about driving.

DONE INCORRECTLY:   The resident did not seek to understand what was important to you about driving.

 MANAGEMENT

  1. The resident gave me a clear recommendation about my driving.

DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:        The resident stated clearly their opinion about whether or not you should continue to drive or have a driving test.

DONE INCORRECTLY:   Recommendation was not clear.

  1. The resident asked me my reaction to his/her recommendation.

DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:        The resident asked in an empathetic manner what you thought about the recommendation.

DONE INCORRECTLY:   The resident asked you if you were going to follow the recommendation.

  1. The resident acknowledged the importance that you remained in your home.

DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:        The resident makes an empathetic statement, e.g. “I know it is important for you to stay in your home.” or “I want you to stay in your home as long as it is safe for you to do so.”

DONE INCORRECTLY:   The resident stressed importance of safety over your desire to live independently.

  1. The resident explored other options for obtaining transportation/needed services, or offered a referral to a social worker, or recommended that you take a driving test.

DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:        The resident discussed other options for obtaining necessary transportation, asked you to think about them out loud, or offered a referral to someone who could help you think about options for transportation that would allow you to live in your home.

DONE INCORRECTLY:   The resident only offered you one option, or did not seem willing to explore other options with you.

 PATIENT-PHYSICIAN INTERACTION

  1. The resident introduced him/herself to me.

DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:        The resident told you their LAST name AND that they were a resident physician.

DONE INCORRECTLY:   The resident ONLY told you that she/he was a resident OR that he/she was asked to come and see you.

  1. The resident behaved warmly, but professionally throughout the entire encounter.

DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:    The resident respectfully demonstrated genuine care and concern.

DONE INCORRECTLY:     The resident demonstrated genuine care and concern, but was overly familiar or personal with you.

NOT DONE:     The resident was cold and distant OR condescending OR overly informal and chummy.

  1. The resident used words I could understand.

DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:        You (as the patient) understood all the terms.

DONE INCORRECTLY:   More than two terms were unfamiliar to you.

NOT DONE:   Pretty much everything the resident said to you was in “medspeak.”

  1. The resident encouraged me to ask questions and never avoided giving me an answer.

DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:        The resident specifically asked if you had questions – and answered them directly or promised to get the answer for you.

DONE INCORRECTLY:   The resident did not specifically ask you if you had questions but gave you the impression that you could ask questions and that you would get a direct answer.

NOT DONE:    The resident never asked if you have any questions, gave you the impression of not being open to questions OR avoided answers to anything you ask.

  1. The resident took into account my concerns when discussing their recommendation about my driving.

DONE CORRECTLY        NOT DONE