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Dina Sokolova (Pavel Sokolov)

 


 

Case Focus:
Language barrier and different explanatory models of hypertension treatment

Presenting Complaint: Patient is coming in for routine follow-up visit to Family Medicine Clinic for hypertension.

CASE SUMMARY:

Dina is a 52-year-old Russian female who lives in Charlottesville. She is a refugee and came with her family from Russia in 2007. She had been diagnosed with hypertension in Russia in 2005 and was given treatment there. She has been followed by learners in Family Medicine for her routine health care and hypertension. She is otherwise healthy. Current medications are hydrochlorothiazide 25 mg once daily and metoprolol XR 50 mg daily. The doctor added the second medication at her last visit 2 months ago because her blood pressure was not well controlled on single therapy.

Unknown to the doctor, Dina does not really understand what hypertension is and why it needs to be treated. She believes that her headaches occur when her pressure is high, and that is when she needs to take her medication. Otherwise, she does not take her medication every day. She has her husband take her pressure when she has a headache, and if it is “high,” she takes both medications or maybe just one or the other. “High” to her is systolic of 150 or so. She doesn’t really understand the lower number (diastolic) pressure.

In Russia, she was treated with a shot once a month at the clinic, so she isn’t that familiar with taking tablets, and definitely not on a daily basis. She worries that she would be taking too many tablets if she were to take them every day as the doctor instructed. Instead, she drinks green tea with sugar and lemon on a daily basis, which she learned from her mother and friends is a treatment for hypertension. In Russia, the doctors never explained hypertension and at Family Medicine she didn’t get any information about the disease either. Dina works in the hospital cafeteria as a salad maker and stands on her feet all day. Otherwise, she gets no exercise and does not understand the role of diet and exercise in hypertension. She eats a fairly high fat and high salt diet.

LEARNER OBJECTIVES:

  1. Work with an interpreter
  2. Use the LEARN model and Kleinman’s explanatory model to discover that the patient is non-adherent to medication use because she lacks understanding of what hypertension is and how it is treated; and
  3. Recommend and negotiate treatment to include daily medication, diet and exercise

Your challenge as the Simulated Patient is:

  1. Appropriately and accurately reveal the facts about Dina Sokolova’s medication usage and limited understanding of hypertension
  2. Observe the resident’s behavior while performing the role; and
  3. Accurately recall the resident’s behavior and complete the performance checklist

Presentation/Emotional Tone:

You are friendly and happy to be seeing the doctor. You answer questions freely and without embarrassment, but don’t ask too many questions yourself.

Beginning of the Encounter:

You are respectful of the physician and friendly. When asked “What you are here for today?” you say:

“For blood pressure.” “I have also been having some headaches, once or twice a week, mostly when I feel a little stressed or tired.”

Throughout the Encounter:

You are mainly going to be answering the questions posed by the doctor. However, with the right questions, you will reveal that you are having your blood pressure taken by your husband when you have a headache, and if your pressure is high, that is when you take one or both medications. You think it is the “water pill” (the first medication prescribed) but are not sure, and you did not bring your medications in with you today. You do not generally take your medications every day, and are not sure why you would need to. No one has ever explained what hypertension is and why it needs to be treated, especially when you are feeling fine most days. The doctor mentioned diet and exercise a couple of times, but never explained what kind of diet and exercise or how often, so you didn’t know what to do.

PAST MEDICAL HISTORY:

No allergies
Medications as above
You are in good health except as above
Two normal deliveries, no other hospitalizations

SOCIAL HISTORY:

You have two children, ages 30 and 28, who are married and living in Charlottesville in their own homes with their families. You have been married for 32 years and your husband works as a painter. You have a 12th grade education and can read and write in Russian. You can only speak a few words of English, and are finding it difficult to learn English.

SUBSTANCE USE: You do not smoke, drink or use illicit drugs.