Resident Instructions

Open Resident
Instructions

 


 
 
CLINICAL PERFORMANCE EXAMINATION (CPX)

 

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