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John Harrison
 


 

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 82 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 76 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.