STANDARDIZED PATIENT CASE - POGOe



|CLINICAL SIMULATION | |

|Clinical Education & Assessment Center | |

|Standardized Patient Lab | |

HENRY CORBETT

CASE DIGEST

|Case Name |

|HENRY CORBETT |

|student Group |

|OMS4 - Fundamentals of Medicine II |

|Department |

|UMDNJ SOM Geriatrics/ Academic Affairs |

|Derivation |

|Created |2011 |Geriatrics/New Jersey Institute for Successful Aging |

| | |Sima C. Bennett, MPH, RD , Clinical Education & Assessment Center |

| |2012 |Geriatrics/New Jersey Institute for Successful Aging |

| | |Sima C. Bennett, MPH, RD , Clinical Education & Assessment Center |

|content/concepts/FocuS |

|Purpose |To challenge students to manage a common geriatric presentation as part of a capstone examination. This encounter is one of several encounters constituting the Clinical Skills Competency Exam.|

|Planned Outcomes |Students conduct a focused history and physical exam to assess contributing causes of lightheadedness in an elderly patient and document the encounter using SOAP format. |

|Objectives |To measure students’ ability to do a focused history & physical exam on a patient presenting with lightheadedness |

| |To assess students' ability to identify causes of lightheadedness |

| |To assess students’ ability to recognize orthostatic hypotension secondary to medications |

|Tasks/ Skills |Focused history and physical exam |

| |Assessment of contributing causes of lightheadedness (cardiovascular, blood loss, fluid intake, medications) |

| |ADLs/IADLs |

| |Demonstrate ability to check for orthostatic hypotension |

| |SOAP documentation |

|supportive or related materials or references |

| |

STAGING

|Scenario |

|Senior adult presents to an ambulatory facility with a complaint of dizziness, fatigue and appetite loss. |

|SP Recruiting: |

|Profile |Ideal |Qualifiers |Disqualifiers |

| |75 y.o. male |Senior adult |Appearing out of age range |

| | | |Lower extremity swelling |

| | | |Scars can be incorporated into the scenario. |

|Demands |OMM/OMT |Physical Exam |Communication: Presentation of |Student Assessment |

| | | |history/Response to counseling | |

| |( |( |( | |

|Special equipment/props/staging |

|Setting/Room |University Health Services: Exam room of a an ambulatory facility |

|Special Equipment |(none) |

|Special Supplies |(none) |

|Props |(none) |

|SP Clothing / Makeup |Gown |

|Paperwork |By email or posting | |

| |Orientation Room |(none) |

| |At door |Henry Corbett Chart |

| |In Exam Room (as prop) |Henry Corbett Blood Pressure Findings card |

| | |Henry Corbett Prescription Medication card |

| | |Henry Corbett Over-the-Counter Medication card |

| |Student/Interstation |Henry Corbett SOAP |

| |SP |LS Henry Corbett SP Checklist (completed by SP Evaluator, not SP Actor) |

| |Evaluators |LS Henry Corbett FON |

| | |LS Henry Corbett Special Section/SOAP |

| |Post Session |(none) |

|TIMELINE |

|Time (min) |Session Orientation |Encounter |Interstation Activity |

| |(before encounter) |14 |9 |

|Staging notes |

| |

|CLINICAL SIMULATION | |

|Clinical Education & Assessment Center | |

|Standardized Patient Lab | |

|STANDARDIZED PATIENT SIMULATION GUIDELINES |

|HENRY CORBETT |

|Case Overview |

|Henry Corbett is a senior adult who presents to an outpatient office with complaints of dizziness, fatigue, low energy and loss of appetite. |

|ENCOUNTER SETTING |

|Exam room of an ambulatory (outpatient) medical practice. |

|You have no prior relationship with the student doctor. |

|WHAT GOES ON IN THIS ENCOUNTER |

|Student doctor is expected to review the medical chart before entering the room, take your medical history, perform a physical examination, present a diagnosis and lay out a treatment/work-up plan,. After leaving|

|the room, s/he documents the encounter in a patient note. |

|SP Actor is expected to provide the history provided in this document in response to the student doctor’s questions, cooperate with the physical exam expressing pain and presenting/acting physical limitations as |

|directed in this document. After student doctor leaves the room, SP returns room to start condition, provides any necessary assistance* to SP Evaluator as may be needed, and takes position in preparation for next|

|student doctor. |

|SP Evaluator: Watches encounter and completes SP Checklist as the encounter progresses. May consult with SP Actor* after the student doctor has left the room, if necessary. |

|* Because recording may not cease immediately with the student doctor’s departure from the exam room, all consultation between SP Actor and SP Evaluator must take place in the Viewing Area with the door to the |

|exam room shut tightly behind the actor and the light in the exam room extinguished before the door is opened to avoid disturbance to other SPs and student doctors. Consultation must be conducted in whispered |

|tones and must be kept very brief. It is NOT expected that consultation will be necessary after each student doctor. |

|TIMING |

|Encounter: 14 minutes |

|Completion of SP checklist and transition to next student: 5 minutes |

|PATIENT CHARACTER PRESENTATION: HENRY CORBETT |

|Age Range |75 years old |

|Presentation |Body Language/ Symptom |No distress, but low energy level – not peppy or particularly jovial. |

| |Presentation | |

| |Affect |Good eye contact, not depressed. |

| | |Clearly frustrated and concerned about your condition --- somewhat fearful that it may be permanent – which is brought out in part of your opening |

| | |statement. |

| | |This is no way to live!! |

| |Appearance/ Costuming |Gown |

| | |Otherwise, well groomed. |

|Starting Position |Sitting in the chair. |

|HENRY CORBETT’S STORY |

|Starting position for each encounter: Seated in chair slouched over – indicative of your current state of always being tired and having little energy. When asked to move to the exam table, you do it in a way |

|that illustrates this lack of pep. |

|Chief complaint: I’ve been feeling dizzy and lightheaded. |

|History of Present Illness |

|Dizziness |

|Feel dizzy all the time -- a fairly constant sensation of lightheaded dizziness. Room DOES NOT spin. |

|You have the sensation that you are going to faint pretty much all the time, but you haven’t fainted yet or fallen, although you are now very fearful of falling. Because of this problem, you can not engage in |

|your normal activities, such as bowling, or even driving to get out of the house. In short, your life has been markedly impacted. |

|If asked: Aside from this sensation, your balance is pretty good. |

|If asked: Nothing seems to make this feeling better. It may be a little worse when you stand. Changing your position or moving your head around does NOT seem to have any effect. |

|Symptoms began about 2 months ago, and before then you never experienced anything like this. |

|Getting worse these last 2 weeks. You feel like this all the time |

|If asked: NO heart palpitations, chest pain, shortness of breath, coughing, wheezing. |

|Other Medical History – ONLY IF ASKED |

|High blood pressure |

|Leg Swelling |

|Your get swelling in your legs, mostly at your ankles and feet. When this happens, you take an extra furosemide pill (brand name: Lasix; commonly referred to as a “water pill”), and this does bring down the |

|swelling. You took 2 yesterday. [Note: This is a key piece of information in this case. Do not reveal that you take extra medicine unless the students ask the right questions, such as WHAT DO YOU DO WHEN YOUR |

|LEGS SWELL? Or HOW MUCH LASIX/FUROSEMIDE DO YOU TAKE? Do not give this information away otherwise.] |

|Reveal the leg swelling as soon as students ask you if you have ANY OTHER SYMPTOMS OTHER THAN DIZZINESS. |

|Well my legs sometimes swell up a bit, but I don’t know if that has anything to do with anything. |

|Alternately, students might not ask you about “any other symptoms”. Instead, they may start by asking you what medication you are on. When they see Lasix/furosemide on your list they may ask you WHY ARE YOU |

|TAKING LASIX? before they ask you about “other symptoms.” At any time that they ask you about taking Lasix, explain that |

|I take it for the swelling in my legs. |

|Bowel/Bladder |

|Only if asked, DO YOU HAVE ANY URINARY PROBLEMS? |

|I have an enlarged prostate. For this, you take Tamsulosin. |

|If asked about frequent urination (DO YOU URINATE FREQUENTLY?): |

|Just when I take my extra water pill. (See medications.) |

|If student follows with WHY DO YOU TAKE AN EXTRA WATER PILL? |

|Answer: When my legs swell up. |

|If asked about pain/burning with urination or incontinence: There is neither. |

|If asked about constipation: |

|I have been a little constipated. Usually, I go every day, but not lately. |

|Digestion/Food/Fluid |

|If asked, you have reflux. |

|If asked about your appetite: it’s somewhat diminished of late, and you’ve been getting indigestion, so you have been eating less. |

|I used to eat dinner with my daughter, but she just got a new job so she is too busy. |

|But I don’t seem to have much of an appetite anyway. |

|If asked about fluid intake: You drink water to take your medicine and several glasses during the day. You also drink 1-2 cups of coffee each morning. |

|No nausea or vomiting. |

|General Constitution: |

|No depression, chest pain, palpitations, cough, wheeze, shortness of breath, difficulty sleeping. No hearing loss or changes in vision. |

|You’ve been feeling more tired than usual lately. |

|Medications |

|When – and only when – the student doctor asks about prescription medication, provide the Henry Corbett Prescription Medication card to the student doctor. [No need for you to memorize these drugs or the dosages,|

|but do learn what disorder is being treated by them.] |

|Amlodipine 10 mg po daily -- to treat your high blood pressure. |

|Furosemide 40 mg po daily – a diuretic to help rid your body of extra fluid |

|Enalapril 10 mg qd – to treat your high blood pressure |

|Tamsulosin 0.4 mg qd (30 minutes after a meal) – to treat your enlarged prostate |

|No recent changes in your medication: |

|I’ve been on the same stuff for years. |

|You take all of your medications as prescribed, except you double your furosemide (Lasix, “water pill”) if legs are swollen. |

|You find that you have been taking that extra pill more frequently of late – 2-3 times/ wk -- to keep the swelling in your legs down. In fact, you took 2 yesterday. |

|When – and only when – the student doctor asks about over-the-counter medication, hand over the Henry Corbett Over-the-Counter Medication card to the student doctor. |

|ASA 81mg po daily [baby aspiri] -- for heart health, as advised by your doctor |

|Mylanta -- for heartburn, which has been happening more lately |

|Advil -- 1 each day and more when your back is bothering you. |

|Home Life |

|Live alone since wife died (heart attack).. |

|My wife died a couple of years ago. Now it's just me puttering around the house. |

|My daughter lives pretty close, though she just started a new job and is pretty busy. |

|Hobbies: |

|I enjoy reading, especially Civil War history. I just started a book about Jefferson Davis. |

|My wife and I used to play bridge at the senior center; sometimes, I go over there to play cards. |

|Exercise: |

|I bowl in a senior league. I think that's why my back sometimes hurts, from the twisting. |

|Function: |

|I can get dressed and go to the bathroom myself. |

|I take my medications. |

|I can drive and do my own shopping, keep up with the bills, all that.” |

|Occupation: |

|I'm retired. I was an accountant. Sometimes, I help out during tax season, just to keep my head in the game. |

|Substances |

|Alcohol: Sometimes, I have a beer with dinner. |

|Coffee: I don’t drink much coffee, just a cup or two in the morning. |

|Tobacco, street drugs: Never |

|No allergies, surgeries or other illnesses. |

|You are up to date on your flu vaccine. You received a pneumonia shot about a year ago. |

|Family History |

|Mother died at age 69 of complications of a stroke. |

|Father lived to age 94 -- died of old age. |

|Brother: 79 – has high blood pressure (just like you) |

|Sister: 73. Had a stroke last year. Lives in assisted living facility. |

|She’s close so I try to get out to see her once a week. |

|SCRIPTED REVIEW OF THE HISTORY |

|The student doctor’s task is to: |Examples of correct student doctor actions/questions: |Examples of appropriate responses by you: |

|Ask about the onset of symptoms. |HOW LONG HAVE YOU BEEN HAVING THESE SYMPTOMS? |The dizziness started about 2 months ago, I guess. It has been on and |

| |WHEN DID YOU FIRST START FEELING DIZZY? |off, but fairly constant over the past 2 weeks. |

|Ask if room spins. |DO YOU EVER FEEL DIZZY LIKE THE ROOM IS SPINNING? |No. The room doesn't spin. |

|Ask about lightheadedness or fainting. |HAVE YOU FAINTED? |Sometimes, I feel like I’m going to faint, but I don’t. |

|Ask about passing out. |ANY PASSING OUT SPELLS? |No I have never passed out. |

|Ask about duration of symptoms. |HOW LONG DOES IT LAST? |I feel this way all the time. |

|Ask about falls. |HAVE YOU FALLEN? |No, I haven't fallen. |

|Ask about what makes the problem worse. |WHEN DOES THE LIGHTHEADEDNESS GET WORSE? |I am dizzy all of the time, but it seems worse when I stand. I often have|

| |IS THERE ANYTHING THAT MAKES THE PROBLEM WORSE? |to hold on to something. |

|Ask about prior episodes. |HAVE YOU EVER EXPERIENCED THIS PROBLEM BEFORE? |I don’t remember anything like this before. |

| |HAVE YOU HAD LIGHTHEADEDNESS PRIOR TO THIS EPISODE? | |

|Ask about medications and medication compliance. |DO YOU TAKE ANY MEDICATIONS? |(Hand the list of prescription medications to student doctor.) |

| |DO YOU TAKE YOUR MEDICATIONS AS PRESCRIBED? |Well, I have been taking an extra water pill more frequently to keep the |

| |HAS THERE BEEN ANY RECENT CHANGE IN YOUR MEDICATIONS? |swelling down in my legs. Maybe 2 to 3 times per week. I took two |

| | |yesterday. |

| | |I’ve been on the same stuff for a while now. |

|Ask about over-the-counter medications. |DO YOU TAKE ANY OVER-THE-COUNTER MEDICATIONS? |(Hand the list of OTC medications to student doctor.) |

| | |I take Mylanta when I get heartburn and I take an Advil every day, a few |

| | |extra when my back bothers me. |

|Ask about other, associated symptoms. |DO YOU HAVE PALPITATIONS? CHEST PAIN? SHORTNESS OF BREATH? |No. |

| |VOMITING? | |

|Assess oral intake of food / water; assess diet. |HOW IS YOUR APPETITE? |Okay, but I have been getting indigestion lately so I have been eating |

| |WHAT DO YOU EAT? |less. I don’t seem to have much of an appetite anyway over the past few |

| |TELL ME WHAT YOU HAVE FOR YOUR MEALS ON A REGULAR DAY? |weeks. |

| |WHAT IS YOUR FLUID INTAKE EACH DAY? |Normal stuff – maybe a little cereal in the morning. A sandwich at lunch.|

| | |Some kind of dinner at night. A TV dinner sometimes. My daughter often |

| | |sends me care packages. Occasionally, I’ll make eggs or something easy |

| | |for dinner. |

| | |I use to eat dinner with my daughter, but she just got a new job so she is|

| | |too busy. |

| | |I drink a glass of water to take my medicines and several glasses during |

| | |the day. I have a cup or two of coffee in the morning. |

|Ask about living situation. |DO YOU LIVE ALONE? |Nope, been on my own since the wife died. |

| |DO YOU LIVE BY YOURSELF? | |

|Ask about symptom impact on patient's function. |HOW ARE YOU FUNCTIONING AT HOME? |I can get dressed and go to the bathroom myself. I take my medications |

| |DO YOU TAKE CARE OF YOURSELF? |also. I drive and do my own shopping. |

|Auscultate the heart. | | |

|Check lower extremities for pitting edema. | |My legs get swollen, mostly at my ankles and feet. But, I take an extra |

| | |pill to keep it down. |

|Check blood pressure supine and standing. | | |

|Checked for epigastric tenderness. |DO YOU HAVE ANY TENDERNESS IN THIS AREA? (upper abdomen) |Yes, it is a little tender or Respond with tenderness when abdomen is |

| | |palpated in upper area |

|PHYSICAL EXAMINATION |

|Allow your body to respond normally and naturally to any physical examination techniques utilized by the student doctor. At a minimum, you should expect them to do the following: |

|Auscultate (listen to) your heart. |

|Check lower extremities for edema. Properly done, this should involve their pushing against the skin of your legs/ankles with a finger tip and observing whether the finger tip leaves an impression when it is |

|removed. |

|Check your blood pressure in supine (lying down) and standing positions. Only if the student doctor measures BOTH of these blood pressures do you hand him the prop Henry Corbett BP card. [We assume that your |

|blood pressure does not match what Henry Corbett’s blood pressure would actually be and, therefore, provide BP readings that more appropriately match Henry’s medical presentation.] |

|Palpate your upper abdomen for tenderness. When pressed, you do have a small amount of tenderness in the area indicated . |

|CLOSING |

|After completing the history and the physical examination, the student doctor should summarize his findings of your condition and lay out a plan of care. For this scenario, the plan of care is expected to include|

|osteopathic manipulative therapy which is performed as part of the encounter (see Section 10). |

|Student doctors often close the encounter by asking if you have any questions. You have no questions. |

|When the student doctor leaves the room, dispose of any papers the student may have left behind. Unless you are needed by the SP evaluator, seat yourself in the side chair and await the Ready announcement to |

|commence with the next student doctor. |

| Osteopathic treatment |

|No osteopathic treatment is indicated in this encounter. None is expected by students. If students do wish to treat you osteopathically, agree to their requests.. |

|CONDUCT EXPECTATIONS FOR STANDARDIZED PATIENTS |

|Successful execution of the SP role requires you to study and commit to memory the details of your patient’s life and illness/complaint. However, you are also required to provide these details judiciously – |

|paying close attention to what is asked by the student doctor and providing that information and no more. Providing too much information in a single answer leads to student doctors being awarded performance |

|points which they did not actually earn and will thus distort the assessment of their true skills. Beginning in 2012, SPs will be subject to quality assurance checks to assess accuracy and fidelity in their |

|performance. |

|In order to preserve the authenticity of all encounters, please refrain from all conversations and interactions with student doctors while in the suite and anywhere on campus while out of character, unless |

|specifically dictated by our programming. |

|While you are in the CEAC, please maintain as much physical distance between yourself and the student doctors as possible while you are out of character. This may include avoidance of common areas and spaces |

|where students gather. At the conclusion of your assignment, please refrain from assembling in the reception area. Kindly wait in the Break Room. |

|While student doctors are moving about between exam and feedback rooms, enter and exit your assigned exam room exclusively through the Viewing Area to avoid contact with them while you are out of character. |

|After a student doctor has left the exam room, under no circumstances should SPs ever comment positively or negatively about the student’s performance or appearance or any other characteristic. Digital recording |

|does not necessarily cease when the student exits the room and continued activity or dialogue may be captured. Judgmental behavior that is not associated with an SP checklist may appear unseemly and is to |

|contrary to our goal of maintain a neutral, objective and comfortable environment for teaching and testing. Moreover, the recordings are viewed by faculty evaluators and, often, the student doctor himself and |

|other SPs.. |

|Use of cell phones by SPs to carry on telephone conversations while in the exam rooms – whether on duty or on break – is expressly forbidden. Telephones must be off or silenced; vibrate mode is not acceptable. |

|Telephones may be used in the exam rooms for text messaging by SPs on break but not between students while on duty. Violation of these rules may result in dismissal from our program and are not negotiable. Any |

|SP expecting an important telephone call while on duty is welcome to leave his/her telephone with CEAC staff and, depending on the nature of the incoming call, will be notified at the first available opportunity |

|at the discretion of CEAC management. |

|STANDARDIZED PATIENT SAFETY |

|Fire exit signs are posted at the ends of Hallways C and D. Please familiarize yourself with them before the encounter. In the event that the fire alarm sounds, immediately break character and exit the suite |

|through the nearest fire exit. |

|In the event that you experience a true medical emergency while you are in character and are able to express your needs, please inform the student doctor or a staff member that you are out of character and in |

|distress. It is important that you clearly announce to the student doctor that you are out of character, as student doctors may initially assume that your distress call is part of the simulation. Emergency |

|services will be obtained for you ASAP. |

|In the event that a student doctor causes you discomfort, distress or pain, you may come out of character at your discretion or choose to wait until the end of the encounter. You may also state, “That’s a bit |

|rough, Doctor.” Students understand this as code that they must back off their technique and use a gentler approach. Please notify CEAC staff as soon as possible so that your needs can be addressed. |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download