Sample Case Scenarios



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Case Scenarios


Scenario 1

P.W. is a 77-year-old female with a history of upper GI bleed, indeterminate pulmonary nodules, and more recently decreasing functionality at home involving muscle weakness and hand swelling, who presents today for follow-up of her hand swelling and urinary incontinence. She was living in downtown cville and was interested in going to an assisted living facility, but her sons refused to support her in that decision due to poor outcome with another family member. She can no longer comb her hair, and refuses any blood draws and most medication, though is otherwise cognitively intact.

She has, instead, moved out into the country to live with her sons, where she may have less access to med facilities/nursing care. APS have already been involved.

How do I handle her refusing to work things up but presenting over and over with new problems? I’m so frustrated at her sons for not supporting her assisted living facility goals (there may be financial issues here I’m not fully aware of).

Scenario 2

Mr. A is a 78 year old retired Anglican Priest with mild Alzheimer’s dementia. He lives with his wife, who still works. He drives to Barracks Road for lunch every day, and has never had an accident. He has a h/o HTN and Hyperlipidemia, and he is on galantamine for his dementia. He also takes lisinopril and hctz. He has had some trouble with depression, which has responded well to celexa.

When should he stop driving? How do I evaluate him for this?

Scenario 3

Mr. Y is an 84 y/o man whom lives with his wife and daughter. He has issues of stability and falls frequently. He refuses to go to a nursing home – he also refuses home health physical therapy. He also refuses to go to an senior community center with his wife for daytime activities. The last time he did go – he cursed at people and was told he is not welcome anymore if he continues to exhibit this behavior. His family no longer goes out anymore to stay at home to take care of him.

Scenario 4

Mr. C.A. is a 75 y.o. male with a hx of pulm htn, CHF, lymphedema with chronic wounds, HTN, and CKD presenting in WI clinic for follow up on his multiple medical issues.

Items I found challenging:

  1. Sorting through the concerns that were voiced- daughter, wife and patient all seemed to have differing opinions. hard to tell who was most important to listen to.
  2. Prioritizing his medical issues in the context of his complaint (he was worried about his legs, so was I but I was also worried about his shortness of breath and CKD!)
  3. Digging through his notes to figure out what would be the appropriate next step in his management.

Scenario 5

79 y/o African American lady with long standing, well controlled HTN and questionable pulmonary disease.

She does have a h/o asthma but this has not been active for 30+ years. When I inherited her she had a diagnosis of COPD but given her disposition/age, she has been unable to perform PFTs. Her cxr’s look fine. ECHO shows some diastolic dysfunction.
with this she persistently c/o subjective shortness of breath and nocturnal cough.Sshe is on optimal COPD meds, intermittent lasix, albuterol all offering some relief.

The challenge with her is:

  1. I can’t get PFTs on her: she cannot do them
  2. She is not interested in many interventions/changes
  3. She gets confused easily with medications, changes etc
  4. She lives by herself and comes in by herself so I don’t have a friend or family member to help with her management/insights (though i have been in contact with her daughter who live in Maryland)
  5. She does not want to schedule visits often (2 months is the quickest f/u she wishes to do)
  6. She told me “she’s used to having a male doctor” but is willing to “stick with” me
  7. I am not sure what else to offer her and it seems we are just status quo but she does state that she is doing ok and her SOB is not worse nor much better on meds

Scenario 6

75 y/o female initial visit who has not seen a physician for over 20 years, presenting for progressively increasing confusion and hallucinations. Patient claims to occasionally see small gnomes on the front lawn for which she has called the police. She has full ADLs and is not seem altered or confused during the clinic session. Subsequent consults to neuro feel that patient may have Lewy body dementia but they are not certain. Psychiatry feels that patient should see them regularly and start Seroquel. Patient lives at home alone but close to daughter’s house. Caretaker occasionally visits but patient is predominantly alone. Patient has no significant PMH, no medications, does not smoke, drink alcohol or use any other drugs. The patient does not wish to see any other doctors other than myself and does not want to take medications. The daughter is not sure what to do.