Standardized Patient Materials

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Training Materials

Mrs. Hassan

SP Training Materials^


Case Focus:    Diagnosis and treatment of emotional illness among refugee patients (in this case post-traumatic stress disorder with depression).

Presenting Complaint:    Follow-up for complaint of pain in multiple sites.


CASE SUMMARY:
 

Mrs. Hassan is a 45-year-old Iraqi woman who has been in the U.S. for 8 months. She fled from Iraq to Jordan with 3 of her children after her oldest son had been threatened with death by a rival religious faction. Her husband was killed when a bomb hit his office in Bagdad 12 months before that. One daughter, who is married with a young child, remained behind in Iraq with her family.

Mrs. Hassan has been in to see her primary care doctor and other clinicians at Family Medicine several times since arriving. She has been complaining of pain in different parts of her body, including headaches, backaches and abdominal pain. She has been extensively evaluated with brain MRI and a number of other x-ray and blood tests. Nothing was identified, and she is being treated for mild reflux, tension headaches and mild osteoarthritis.

Mrs. Hassan is back to see the doctor for follow-up of the above. She is still having most of her symptoms. In addition, she is crying almost daily, has no interest in things and has poor appetite, energy and concentration.

She is also experiencing other symptoms that she hasn’t told the doctors about because no one has asked her about these and she didn’t think it was important to bring up. These include terrible nightmares that occur almost nightly about her husband and his death. She didn’t directly witness his death, but had to go to the morgue to identify his body. She finds it difficult to listen to or watch the news – as soon as she hears of bombings or killings in Iraq, she gets very upset and irritable, cannot concentrate and has trouble sleeping. Additionally, although she wanted to stay in direct communication with her daughter in Iraq, these conversations were making her very anxious and jumpy.

Mrs. Hassan was a teacher in Iraq and speaks fluent English.


LEARNER OBJECTIVES:

  1. Conduct a focused interview to evaluate the emotional status of a refugee patient
  2. Be able to diagnose depression and post-traumatic stress disorder
  3. Know how to treat the disorder; and
  4. Identify and address common barriers to treatment of emotional disorders among refugee patients

Your challenge as the Simulated Patient is threefold:

  1. Appropriately and accurately reveal the facts (and emotions) about Mrs. Hassan’s symptoms and medication usage
  2. Observe the resident’s behavior while performing the role; and
  3. Accurately recall the resident’s behavior and complete the performance checklist

Keep in mind that as Mrs. Hassan you don’t understand some of the medical terms for emotional problems, such as “depression,” so if the resident uses such terms, be sure to act unsure and ask what that means.


PRESENTATION/EMOTIONAL TONE

You are respectful to the resident and willing to share your story with the proper prompting/questions from the resident. There are times when you must stop to compose yourself, as it is very difficult to tell the story. At the same time, it is a relief to share your grief and tell someone about it. With gentle probing or encouragement, you resume telling your story.

Beginning of the Encounter:

The resident will ask how you are feeling and you will say:

“I feel about the same as before.”

Throughout the Encounter:

You are taking the pain medication (acetaminophen or Tylenol brand name) and antacid for your stomach (ranitidine). The residents will know that this SP case will be focusing on mental health, and they will know what your current diagnoses are and what medications had been prescribed for you. They won’t know too much about your social history and other symptoms described above or about your experiences, except that you are a widow with 3 children here in Charlottesville. They don’t know how your husband was killed or that your daughter is still in Iraq with her family.


PAST MEDICAL HISTORY:

The pain symptoms as well as emotional symptoms began soon after your husband’s death in Iraq and became worse after coming to the U.S. and being separated from your daughter and her family. Prior to that, you had been in good health. You were hospitalized only for childbirth.


SOCIAL HISTORY:

You are a widow with four children. Your oldest daughter is 26 and lives in Bagdad. The rest of the children live with you in Charlottesville (20 year old son, 15 year old daughter, 12 year old daughter). Your son works doing landscaping, the daughters attend school. You are not working yet due to the various “medical problems” you have. Money is tight and you feel bad that your son has to support the family. You are Muslim.


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

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Open Resident
Instructions

CLINICAL PERFORMANCE EXAMINATION (CPX)

Resident Instructions^

 

Station Length:          15 minutes maximum

Patient Name:            Hassan

Resident Instructions:

Mrs. Hassan is a 45 year-old Iraqi woman who has been in Charlottesville for 8 months. She fled from Iraq with 3 of her children to Jordan, and then to the U.S, where she is being helped by the IRC. Mrs. Hassan has been in to see you, her primary care doctor, and other clinicians at Family Medicine several times since arriving. She has been complaining of pain in different parts of her body, including headaches, backaches, and abdominal pain. She has been extensively evaluated with brain MRI and a number of other x-rays and blood tests. Nothing was identified, and she is being treated for mild reflux, tension headaches and mild osteoarthritis. You are seeing her today for follow-up. At today’s visit, you have decided to focus on her psycho-social issues. You have not taken an extensive psycho-social history in the past.

 

Once you have obtained a focused history, you are to leave the room and complete a checklist on the computer.

 

 PLEASE DO NOT WRITE ON THIS PAGE

 

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Open Patient Chart

Patient Chart^

 

Temp                                 BP                                        HR                            

Patient Name    Hassan                             Patient Age                 45     

History Number  022557                            Chart Number             086254                   

RR                               HT                               WT                           

Complaint:                Follow-up for complaint of pain in multiple sites.      

Nurse’s signature        Diane Walters                          

Copied                                    Dictated

 

Reviewed w/attending

 

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Open SP Checklist

 Iraqi Patient Mrs. Hassan 45 y.o.

Standardized Patient Checklist^

 

Conducting a Mental Health Examination/Post-Traumatic
Stress Disorder with Depression and Providing Appropriate Treatment

 

Your Name ______________________ Resident Name _____________________

 

  1. The resident appropriately greeted me and asked me how I have been feeling since my last visit.

 DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:     The resident appropriately greeted and asked the patient how she has been feeling/doing since her last visit.

DONE INCORRECTLY:   The resident appropriately greeted OR asked how she has been feeling since her last visit.

NOT DONE:     The resident did not ask either.

  1. The resident probed for specific symptoms that are associated with depression, including appetite, sleep habits, energy level and crying spells.

DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:     The resident asked about at least 3 specific symptoms.

 DONE INCORRECTLY:   The resident asked about only 1-2 specific symptoms.

 NOT DONE:   The resident did not ask about any of these symptoms.

  1. The resident asked me if I am experiencing any of the following symptoms that are associated with post-traumatic stress disorder: nightmares, irritability, avoidance behavior (such as avoiding TV or radio news), or intrusive thoughts.

DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:     The resident asked about at least 2 of these symptoms.

DONE INCORRECTLY:   The resident asked about only 1of these symptoms.

NOT DONE:    The resident did not ask about any of these symptoms.

  1. The resident followed up on these symptoms by asking me if they relate to real events that occurred in my life in Iraq. For example, if nightmares are mentioned, the resident would ask if the nightmares are about real events that happened to me.

DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:     The resident followed up on all the symptoms described by the patient under #3.

DONE INCORRECTLY:   The resident followed up on only 1-2 of the symptoms.

NOT DONE:    The resident did not follow up on any of the symptoms.

  1. The resident probed more to learn about events in my life before coming to the U.S. (i.e., “Tell me more about what happened in Iraq that led to your leaving/becoming a refugee.” “How did you become a widow?” “Do you have any family back in Iraq?”)

DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:     The resident probed about other events in the patient’s life before coming to the U.S.

DONE INCORRECTLY:   The resident probed a little, one or two questions.

NOT DONE:    The resident did not probe at all.

  1. The resident responded with sympathy and understanding of the difficulties I have experienced.

DONE CORRECTLY        NOT DONE

DONE CORRECTLY:     The resident expressed compassion for the patient’s loss and understanding of how difficult that must be.

NOT DONE:    The resident did not express compassion or understanding.

  1. The resident explained the relationship between my psychosocial trauma and my current symptoms, both physical and mental (e.g., “You went through very difficult events in the past and now your body and mind are reacting to those events, giving you many of the symptoms you are having now – nightmares, avoiding TV or calling your daughter, poor sleep, poor concentration.”)

DONE CORRECTLY        NOT DONE

DONE CORRECTLY:     The resident explained the relationship between the patient’s psychosocial trauma and her current symptoms.

NOT DONE:    The resident did not explain the relationship between the patient’s psychosocial trauma and her current symptoms.

  1. The resident prescribed medication to treat my emotional symptoms.

 DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:     The resident prescribed medication, explaining it will help the patient reduce her symptoms such as nightmares.

DONE INCORRECTLY:   The resident prescribed medication, but did not explain the reason for giving it.

NOT DONE:    The resident did not prescribe any medication.

  1. The resident explained the appropriate way to take the medication.

DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:     The resident explained that it needs to be taken for at least one month to see effects.

DONE INCORRECTLY:   The resident said the patient needs to keep taking it without explanation as to how long it takes to see beneficial effects.

NOT DONE:    The resident did not advise how long to take it or the reason why.

  1. The resident recommended that I continue taking the medication on a daily basis until I return to see him/her and explained refills.

DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:     The resident recommended that the patient continue taking the medication until the next visit AND explained refills.

DONE INCORRECTLY:   The resident recommended taking the medication until next visit but did not explain refills.

NOT DONE:    The resident did not provide medication instructions.

  1. The resident asked me to repeat the medication instructions to ensure that I understand them.

DONE CORRECTLY        NOT DONE

DONE CORRECTLY:     The resident asked the patient to repeat the medication instructions.

NOT DONE:     The resident did not ask the patient to repeat the medication instructions.

  1. The resident asked me if I agree with the plan or have other things to suggest.

DONE CORRECTLY        NOT DONE

DONE CORRECTLY:     The resident asked the patient if she agrees with the plan or has other things to suggest.

NOT DONE:    The resident did not ask the patient if she agrees with the plan or has other things to suggest.

  1. The resident recommended counseling.

DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:     The resident recommended counseling and explained how this will be arranged.

DONE INCORRECTLY:   The resident recommended counseling but did not provide any explanation about how it will be arranged.

NOT DONE:    The resident did not recommend counseling.

  1. The resident used easy to understand words for my “diagnosis” instead of technical medical terms.

DONE CORRECTLY        DONE INCORRECTLY        NOT DONE

DONE CORRECTLY:     The resident used easy to understand words such as “sadness” rather than medical terms such as “depression” or “Post-Traumatic Stress Disorder.” If the resident used these terms, s/he explained them.

DONE INCORRECTLY:   The resident sometimes used medical terms and/or didn’t explain them.

NOT DONE:    The resident only used medical terms.

  1. As a patient, I would want to continue seeing this physician for my future care (circle one):
    1. Strongly Agree
    2. Agree
    3. Neutral
    4. Disagree
    5. Strongly disagree
  1. Comments (if needed):