Interprofessional Standardized Patient Exercise: Patient ...



Interprofessional Standardized Patient Exercise: Case SummaryPatient Name: Elsie SmithPresenting Problem:Patient presents to establish care after an Emergency Department visit for a fall. Her main complaints are balance problems and right jaw pain.Actual Diagnoses:Diabetes mellitus type 2Peripheral neuropathy HypertensionHyperlipidemia Chronic kidney disease OsteoarthritisGlaucomaAnxietyXerostomiaReversible pulpitis due to extensive caries under right mandibular molar bridge abutment crown.Generalized moderate periodontitis, with localized severe periodontitisPatient Demographics:Age: 75 years old Sex: FemaleRace: OpenHeight: averageWeight: Overweight or averageOverview of Case:Elsie Smith is a 75 year old woman who comes to your UCSF clinic for the first time. She has not seen a doctor for about a year as it has been increasingly difficult to leave her home. Your clinic is closer to her home and easier to get to. Ms. Smith has diabetes, peripheral neuropathy, osteoarthritis, and glaucoma. She is running out of her medications and needs refills. She has fallen several times over the last several months and is very fearful of falling. In her last fall, she hit her lower jaw, which has been hurting since. The goal of the visit from the provider’s perspective is to become acquainted with the patient, to acquire relevant information about her chronic health conditions, to inquire about her adherence to her drug regimen and other health related behaviors, and to prevent future falls. The patient’s agenda is to establish care in order to get medication refills, to prevent future falls, and to evaluate her right jaw pain. PRESENTING SITUATION and INSTRUCTIONS TO THE STUDENTElsie SmithElsie Smith is a 75 year old woman with diabetes, hypertension, osteoarthritis, anxiety, and glaucoma who presented to the Emergency Department (ED) two weeks ago after a fall. She complained of right jaw and knee pain for which x rays were taken in the ED and showed no fractures. She has not seen a doctor for almost a year as it has been increasingly difficult to leave her home. Your clinic is closer to her home and easier to get to. She is here for follow-up of her ED visit and to establish care in your clinic. You have some records (see below) from the ED.Vital signs: Prescription Medications:Temperature: 37.2 CLantus 15 units at bedtimePulse: 72Glipizide 20 mg twice a dayRespiration: 14Lisinopril 10 mg dailyBlood pressure: 152/89 Hydrochlorothiazide 12.5 mg dailyO2 Saturation: 100% on room air Aspirin 81 mg dailyLipitor 80 mg dailyNeurontin 900 mg three times dailyBetaxolol 1 drop daily right eyePilocarpine 4% 1 drop four times daily right eyeVicodin 5/500 mg 1-2 tabs two times daily as needed for painLorazepam 0.5 mg three times daily as needed for anxietyHeight: 5 feet 2 inchesWeight: 155 poundsLabs/Studies: (from ED visit 2 weeks ago)Cholesterol 285 mg/dl (high)Na+ 140 mmol/L (normal)K+ 4.0 mmol/L (normal)HDL 38 mg/dl (low/normal)Cl- 101mmol/L (normal)BUN 18 mg/dl (normal)ALT 35 U/L Creatinine 1.3 mg/dl (abnormal)AST 40 U/L GFR 51 mL/min/1.73 m2 (mildly decreased)Total bilirubin 1.0 mg/dl (normal)HbA1c 8 (high)Studies: (from ED visit 2 weeks ago)Right knee x-ray: marked tricompartmental joint space narrowing consistent with moderate degenerative joint diseaseJaw x-ray: no fractureYou are to:Take a relevant history.Perform an appropriate focused physical exam for your profession.Tell the patient what you think is going on with her and develop a plan for helping her better manage her chronic medical conditions.Each group participant will have 15 minutes to perform these tasks.You will hear an intercom announcement when there are 5 minutes remaining and another when the encounter is over, at which time you must leave the room. You will then have 5 minutes to discuss your finding with your team outside the patient room. You will then observe the rest of your team members for the remainder of the interviews.Patient Profile:You are Elsie Smith, a 75 year old retired hotel laundry worker. You previously got your healthcare from a community physician, but you stopped going to see her a year ago because her office was too far from your home. You are widowed and live alone. You have an In Home Support Services caregiver, Mildred, 4 hours 3 days a week to help you with your daily living. You are taking a complex medication regimen, and want to figure out if you really need all these medications. However, your top priority is to figure out how to keep from falling again, and to fix your jaw pain.Presentation/Emotional Tone:You are very fearful of falling again and especially of falling in public. You have been limiting your activities outside and you feel isolated and lonely. You know you have a lot of medical and dental problems and are a little overwhelmed by your medication regimen. In particular, you have difficulty with taking your insulin and eye drops. It is also difficult for you to monitor your blood sugar levels. You are somewhat anxious but cooperative with the healthcare providers. You are hopeful they can help keep you from falling, fix your jaw pain, and simplify your medications. You will smile, at times, but be careful not to become too cheerful, when talking with the students. You are sitting on the exam table in a hospital gown over underpants, brassiere and socks, facing towards the right (wall-mounted BP cuff is to your right) with a stool directly in front of you. You will have your handwritten medication list and your list of sugar readings in your handbag, which is next to you on the table. You sit with a slightly hunched posture.History of Present IllnessOpening Statement (For 1st encounter; modify as appropriate during subsequent encounters with students who have observed the 1st encounter):When asked what brings you in to the clinic you reply: Two weeks ago I went to the Emergency Room after I fell at home and hit my knee and jaw. They wanted me to follow up with my doctor but her office is too far away so I came here. I’m scared of falling again; I’ve been falling too much. I also need to get refills of all my medications and get a new doctor as getting to my other doctor’s office is just too hard.If asked what was done in the Emergency Room:They took blood tests and X-rays of my knee and right jaw. They said the X-rays didn’t show any broken bones of my knee or jaw. They told me that I have arthritis in my knee. Were you seeing your doctor regularly before you stopped going?I saw my previous doctor regularly. How often? Once every 3-4 monthsQuestions related to your last fallTell me the circumstances of your fall (the one that lead to the ED visit):I was hurrying to the bathroom after eating lunch. My legs gave out and I fell and hit my right jaw against the coffee table. I also hit my right knee. My caregiver couldn’t get me up so she called 911 and they took me to the hospital.Did you lose consciousness?No, I don’t think so.Did you hit your head?No, just my jaw. And that hurt! It still hurts.Did you feel any symptoms (chest pain, shortness of breath, rapid heart rate, etc) before you fell? No.Did you have any other injuries besides your jaw?I landed on my right knee, but it’s much better now.Have you fallen since the Emergency Room visit? No.Questions about Past Falls and Falls in GeneralHave you ever fallen before?Yes, I’ve fallen several times over the past few months but this last time was the worst.What are you usually doing when you fall?Sometimes when I hurry to do something, like go to the bathroom, it seems like my balance gets worse. One time I tripped on the edge of my rug. Have you ever lost consciousness with these previous falls? No.Did you ever hit your head? No.Did you ever feel any symptoms (chest pain, shortness of breath, rapid heart rate, etc) prior to these past falls? Only one time I felt a little lightheaded beforehand.Did you ever have any other injuries due to these past falls? No.Has anyone witnessed any of your falls? No. (When Mildred has been there, she didn’t see you fall, but she heard you and came running to help.) How did you get up after these falls? Sometimes, my caregiver got me up. When I was by myself, I crawled to the phone and called my neighbor.Do you fall at certain times of day or night? No, seems like random times.Where do you typically fall? Only in my apartment. I’m so scared of falling outside I don’t go outside anymore.Do you have any steps getting into your apartment (i.e. a step up or down into the apartment)? No.How is the lighting in your apartment? Pretty good. I have a lot of lamps. Is your apartment neat/clean or cluttered? It’s cluttered. It’s a small place.Do you have pets in your home? No.Questions about your balanceWhy do you think you’re falling so often? I don’t know. I think it’s because I’m losing my balance more. The one time I tripped on the rug. Another time I was kind of lightheaded beforehand. I just don’t know.Do you have trouble walking? Yes, I do. My balance isn’t so good. Do you have trouble with your balance? Yes. I do feel unsteady.Why do you think you have balance problems? My legs don’t seem so strong; they give out sometimes. And the feeling in my feet is off and my doctor said this was because of diabetes.Questions about other problems related to your fallingDo you have problems with your vision? One eye is pretty blurry – the one with glaucoma. I can see enough to get around my place though. Can you see enough to watch TV/read a newspaper? Yes.Have you ever used a walker or cane to walk?No. Using a cane would make me feel old.Are you getting extra help since your fall? My caregiver, Mildred, comes in 3 days a week for 4 hours each day. I don’t have any extra help since I fell. (If asked, you would say, she has been coming for a couple of years.)What are your physical activity goals? I want to walk outdoors again.Do you need help with:moving from bed to chair: You can get into/out of bed without difficulty. You are able to get in/out of your recliner when watching TV on your own so far.getting dressed; You get dressed sitting on the side of the bed. walking : You are able to walk in your home without an assistive device although you like to be touching furniture for safety. bathing: You have a regular walk-in shower (no step to step over to get in/out), and you take a shower 2-3 times per week. You have a bar to hold onto to get in/out of shower. You have a regular shower head (no hand-holding shower head). Other days you bathe at the sink. Your caregiver is there on some days to help if needed but so far you can do it alone. (Mildred makes it easier for me!)toileting; You get on/off toilet with help of a grab bar. How did you get here today? My caregiver arranged for a taxi to pick me up.Questions related to right knee painTell me about your knee pain. I landed on my right knee when I fell. It’s been getting better since.Where do you feel the pain? It’s sort of a deep down pain all over the knee (rubbing the top of your right knee)Did you have any swelling or bruising? No swelling. I had a bruise which is gone now.How severe is the knee pain on a scale of 1 to 10? No pain at rest. Mild, general pain when walking (…maybe a 1 or 2 usually)Does anything make the knee pain worse? I have some stiffness in my knee when I walk. I think it is my arthritis. Does anything make the knee pain better? Tylenol helps with my knee pain.How much Vicodin are you taking? Right after the fall I was having a lot of pain, so I took 2 Vicodin tablets twice a day but now I’m only taking Vicodin when my jaw really hurts, sometimes one or two pills a day. What did they find OR what did they tell you in the Emergency Room?They did x-rays and told me I have bad arthritis in my knee but nothing broken.Questions related to right jaw painWhen did it start? It started after I fell and hit my jaw two weeks ago.Where exactly is the jaw pain? It’ s around my right lower jaw. (Point toward the back of the right lower jaw where your last molar tooth will be.)Does it radiate? No.On a scale of 1-10, where would you rate the jaw pain if 10 is the worst pain you have ever felt and 0 is no pain? It’s about a 4-5 out of 10. Can you describe the pain? It is a dull ache type of pain. Does anything make it worse? My bridge is loose so it hurts to chew. I have been eating soft food and soups. (NOTE: if student doesn’t ask about what makes the pain worse, you should volunteer that your bridge is loose and it hurts to chew)Are you eating less due to the pain? I’m not eating as much due to pain. Does the pain interfere with your sleep? No.Have you seen a dentist about your jaw pain? No, but I need to. I think something is wrong with my bridge.Do you think you have a bridge problem? Yes, I think so – the area that hurts is near the back of my bridge.Past Medical History DiabetesYou were diagnosed with diabetes at the age of 35. You know it’s a disease where you have too much sugar in your blood and that some people can go blind because of it. You were initially treated with oral medications and later switched to insulin. You sometimes forget to take the insulin every day.Do you monitor your blood sugar at home? I try to but the machine is a little difficult to use. I have trouble pricking my fingers and getting enough blood on the little strip. When my caregivers are around, they help me and write it down.When do you check your sugars? Usually before breakfast, and sometimes before dinner too.What are your blood sugars? It depends on what I eat – usually around 200 or so.Do you keep a blood glucose log?My caregiver helps me with that when she comes in the morning, before I have my breakfast. I have my sugars from last week with me: (SP should hand over paper with glucose numbers).Mon - 64Tues -- (no caregiver)Wed – 200Thurs -- (no caregiver)Fri - 242Sat -- (no caregiver)Sun – (no caregiver)Have you had symptoms to suggest low sugars (sweaty, shaky, lightheaded, headache, fatigue)? No.Have you had any symptoms to suggest high sugars (frequent urination, thirst, fatigue, blurry vision)?I have blurry vision, but only in the eye with glaucoma. Do you have complications related to diabetes (eye, kidney, or nerve problems)?I don’t think my eye problems are from my diabetes. I don’t think I have any kidney problems. -Have you ever been hospitalized because of diabetes? No.Numbness and tingling in your feet You know this is a complication of your diabetes. You’ve had it for some time. Have you ever felt numbness in your feet or toes? Yes. Do you have numbness or tingling in other parts of your body? No.Do you frequently check your feet for ulcers or cuts? No. I don’t think I’ve had any cuts on my feet.High blood pressureThis was diagnosed in your 40s. You have been taking medication for a long time, but can’t recall what you took for it in the past. You are not sure why you have to take medicine for it in the first place.Do you monitor your blood pressure at home? No. High cholesterolThis was diagnosed in your 40s. You know it is bad for your heart and think it is due to your diet. You also think that as long as you take the medicine, you can eat what you want.Chronic kidney disease NOTE: You are totally unaware that you have any kidney problems. No one ever mentioned this before.ArthritisYou know that you have had arthritis in both knees for a long time. Tylenol effectively relieves the pain.Where is your arthritis pain? In my knees. But it’s not too bad.Does anything make the pain worse? Walking or standing for a long time makes it worse.Does anything make the pain better? It feels better with sitting and resting.How much Vicodin do you take daily for your arthritis? I only take the Vicodin if the arthritis pain is really bothering me, maybe a couple of times a month. I’m taking the Vicodin for the pain in my jaw.Do you also take plain Tylenol for the arthritis? Yes. I take 2 extra strength Tylenol three times a day, Do you take Vicodin and Tylenol on the same day? Yes, sometimes.If so, how much of each? Right after my fall, I took 2 Vicodin twice a day and 2 extra strength Tylenol three times a day for couple of days. Now I’m taking Vicodin 1 tablet twice a day for my jaw pain and 2 extra strength Tylenol three times a day.Do you also take plain Tylenol for the arthritis? No, just the extra-strength Tylenol.GlaucomaYou have had this since your late 40s, when you started using eye drops to treat it. You know that it can cause blindness. Sometimes you forget to put in your eye drops.When was the last time you had your eyes checked by a doctor? About 2-3 years ago. Is your vision worsening? I don’t think so.Anxiety (Nerves)You have been feeling increasingly anxious over the last few years. Living alone and having a lot of medical problems is frightening to you. You have always been a “worrier”, but this has definitely gotten worse over time. You are constantly worrying about everything – falling, becoming a burden on your daughter, finances etc. Your previous doctor gave you a medicine to help you relax, but you don’t take it often because it makes you sleepy. You can take Lorazepam 1 tablet three times a day as needed to control your anxiety. You are not on regular scheduled doses of lorazepam.Dry MouthYou have had a dry mouth for a long time. It is very bothersome, particularly since there seems to be no good way to relieve it. When did it start? It seemed to start when I got some new medicines about a year ago.Do you recall which medicines? No. Have you tried anything to help with the dry mouth?I tried drinking more liquids to keep my mouth wet, but the relief doesn’t last long. Past Dental History:You have not seen a dentist in over 10 years. The only time you see a dentist is when you have severe pain. You know you wait too long before going because “usually all they can do when I finally get there is pull out the tooth.”You are glad to see a dentist today because you have a painful jaw, dry mouth, your bridge is loose, and you know some teeth need to be fixed or pulled. However, you are concerned about how much it will cost to fix the problems.You want to learn how to take better care of your teeth, especially since you have caregivers that can help you now.Questions related to general dental care:If asked about your tooth brushing: Since my caregiver started coming, I usually brush twice a day. If asked how often you floss: I don’t floss.If asked about your mouth rinse use: I don’t use any mouth rinses. They cost too much.If asked the last time you had a dental exam, x-rays or photographs: They did that after I arrived today and checked my teeth and gums. [All of this information will be given to the dental student with the “PRESENTING SITUATION and INSTRUCTIONS TO THE STUDENT” instructions. See Page 2 above.]Past Surgeries History: NoneOB GYN History:Last mammogram about 5 years ago – no problems Last pelvic exam 10 years ago – no problemsWent through menopause 25 years ago – no issuesDaughter delivered vaginally, no complications (your only Hospitalization) Allergies:Penicillin caused a rash when you took penicillin for strep throat as a child. Medications:I have a lot of pills – it’s hard to keep them all straight. I brought this list with me though. (You will give the student your handwritten copy of the PRESCRIPTIONS below if they ask you about medications. NOTE: Please your PRESCRIPTIONS neatly on a small piece of paper or card that should look like something you would keep in your wallet. You will not be provided with extra copies of the list so you will need to make sure the student gives it back to you each time.) PRESCRIPTIONSLantus 15 units at bedtimeGlipizide 20mg twice a day Lisinopril 10 mg daily with breakfast Hydrochlorothiazide 12.5 mg once a day (You will call this a “water pill”.)Aspirin 81 mg dailyLipitor 80 mg dailyNeurontin 900 mg three times dailyBetaxolol 1 drop daily right eyePilocarpine 4% 1 drop four times daily right eyeVicodin 5/500 mg 1-2 tabs two times daily as needed for painLorazepam 0.5mg three times daily as needed for anxietyExplanation of the PRESCRIPTIONS and how you should respond if asked:Lantus at bedtime:It’s for my diabetes, but I don’t always take it because I’m not sure if I’m doing it right. It hurts when I’m injecting it and it’s giving me a weird lump on my stomach where I’ve been putting it. (NOTE: instructional video about injecting insulin by diabetes patient at time of day you take your Lantus: I take it before going to bed. Does your caregiver helps you with your Lantus: No, she leaves before I go to bed.Do you sweat after taking Lantus and/or before a fall: No.Where do you store your Lantus: I keep it in the fridge.How often do you throw away your opened vials? I always throw the opened ones away after a month.How often you change the needle: I change it when it starts to look used. Do you have trouble drawing up Lantus from the bottle:Yes. It is sometimes difficult to read the syringe measurement. I hope I’m getting the right amount of insulin into the syringe.Describe how you inject the Lantus:-check that vial is clear (correct) -pinch skin and inject at 90 degree angle (correct)Glipizide with breakfast and dinner This is for my diabetes. I take this with insulin to control my blood sugar. (pills are round, white, 10 mgs each so you take 2 tablet two times a day)Lisinopril with breakfast I think this is for my blood pressure, but I’m not sure. (The 10 mg. tablets are pink and round.)Hydrochlorothiazide with breakfast. For my blood pressure.Aspirin with breakfast. For my heart.Lipitor at bedtime I don’t remember what it is for. I forget about taking it.Neurontin with breakfast, lunch and dinner. I take these for burning pains and weird feelings in my feet. (These are capsules that come 300 mgs each so you take a lot of these each day.)Betaxolol: (eye drops) For my glaucoma. Pilocarpine: (eye drops) For my glaucoma.If asked how you use your eye drops: Pull out lower eyelid to make a pocket with one hand (correct – should wash hands first)With other hand, squeeze in one drop (correct)Vicodin: I had some left over from a long time ago. I’d really like a refill.How much Vicodin are you taking? I’ve been taking 1 tablet twice a day for my jaw painDo you get constipated taking all this Vicodin? Yes, but it’s not that big of a deal. I’m constipated but I have BM every 2-3 days.Lorazepam: That’s my pill to relax me. How much lorazepam are you taking? I can take 1 tablet three times a day if I need to. I take it about 2-3 times a week, when I am really feeling worried. I don’t take it regularly because it makes me sleepy.Would you be willing to cut back on lorazepam? Yes, I would consider it if I knew there was something else that would help with my nerves.Would you be willing to try Cognitive Behavioral Therapy (or see a therapist, social worker, psychologist)? I don’t know what that is… [once given information] Yes, I’d be willing to try if you think it might help. Over the Counter medications you take (not on your written list) :Extra strength Tylenol 500mg, (Acetaminophen) 2 tabs three times daily for knee and jaw pain: I take 2 tablets 3 times a day for my jaw pain and sometimes my knee pain. It works okay, particularly for the knee pain.General medication related questionsIf asked about your health insurance OR ability to pay for medicines: I have Medi-Cal and Medicare part D. Do you ever get lightheaded when taking any of these medicines at any time in the past? I got lightheaded once which caused me to fall. Usually they don’t make me lightheaded.Do you have trouble remembering to take your medications? I usually forget my eye drops or my insulin and I sometimes forget the Lipitor because it is the only one I take at bedtime besides insulin.How well are you doing taking each of your medications when your caregiver is present? When my caregiver gives the medications, I take all of them.When you are by yourself, how well are you taking your medications? When I’m by myself, I often miss my medications, especially the bedtime doses. I need someone to remind me to take my medications.Would it help to get you a pillbox to organize your medications. Yes.Family HistoryMother: died of pneumonia.Father: died of stomach cancer. You cannot recall their ages at death. Sister, Georgia died 2 years ago at 78. She had diabetes, high blood pressure, and glaucoma. Your other living siblings in Oklahoma, Bill and Jackie, are healthy as far you know.Daughter, 50, is healthy as far as you know.Social HistoryYou grew up in Oklahoma and moved to San Francisco when you were 22 years old. You have 2 living siblings in Oklahoma (Bill and Jackie). You talk to them on the phone about once a month. One of your sisters (Georgia) with whom you were very close passed away 2 years ago. This was hard for you because she lived in the same building as you and was one of your main sources of support. You have a ninth grade education.You worked in various hotel laundries in the city.Your husband (Harold) passed away of a heart attack 10 years ago.Your daughter, Dorothy, lives in Merced. She calls once a week but rarely visits, as she is busy raising 3 young grandchildren (Elsie’s great grandchildren).What is your living situation? You live alone in a one bedroom subsidized apartment unit in the Inner Sunset. What is your financial situation?You have a small monthly pension and social security. It’t enough to pay your rent and expenses, but you have copays for all your medications and they definitely add up. You are able to live on what you have, but have no savings so are worried that if a major expense came up, you wouldn’t be able to afford it.What social support do you have?Your daughter is supportive but lives in Merced in central CA. She is busy with raising her grandchildren. She visits once every three months or so and calls once a week.You feel isolated and lonely especially since your sister passed away 2 years ago.You used to attend the neighborhood church once a week, but over the last few months you stopped attending church because you were so worried about falling and afraid to go on your own.You have a social worker, Anita, who schedules and supervises your caregiver. You don’t have much contact with Anita and have spoken with her on a handful of occasions about your caregiver. Your last doctor mentioned that you should go to the senior center, but getting there, especially now that you are falling, seems overwhelming.What does your caregiver help you with? bathing, dressing, meal preparation, grocery shopping, light housework, and medication reminders on Monday, Wednesday and Friday mornings.What hobbies do you enjoy?A typical day for you: you wake up at 7:30 a.m. and get breakfast. If your caregiver is coming that day (M, W, F), she arrives around 8:00 a.m. and will get you breakfast. She also helps you with bathing and then you dress yourself. If your caregiver is there, you might take a walk to the corner store, but even with her present you have been increasingly reluctant to go out because of fear of falling. You typically nap and watch TV during the day. You have dinner around 5 and go to sleep around 9:00.You used to like to knit or read, but because your eyesight has gotten worse, you stopped these activities.Health Related BehaviorsDo you smoke? I quit 23 years ago. I smoked about a pack per day since my late teens.Do you drink alcohol? I quit drinking liquor about twenty years ago. Do you exercise?You enjoy walking one block up to the corner store but you don’t do it now since you started falling. Are you sexually active? No, not since my husband passed away.Do you use any street/recreational drugs? No. Never have.Questions about NutritionHave you received any nutrition education in the past?I remember my doctor asked me to cut out soda.Have you met with a dietician before? NoAre you interested in receiving nutrition information during your visit?Yes, that sounds fine.Do you currently follow any diet restrictions?I try to stay away from those sweet foods.Do you know what types of foods have carbohydrates? I know sugar is bad for youWhat is your diet like?You eat a lot of canned foods and microwave meals to supplement meals cooked by your caregivers. You love fried foods, especially fried chicken. You like sweets but hardly eat desserts or candy. You prefer salty snack foods like potato chips, and love pasta.What types of meals does the caregiver make for you?She cooks healthy meals most of the time, vegetables, chicken and pasta dishes.What are you eating specifically?Since my jaw hurts, now I am eating soup and soft foods like oat meal, mashed potatoes and rice pudding. What did you eat when your blood sugar was 64? I drank orange juice afterwards.. then I ate my breakfast.What did you have to eat yesterday?For breakfast, some oatmeal. For lunch, I can’t remember! For dinner, I ate some mashed potatoes and vegetable soup. What are you drinking during the day? Tea.If asked, what do you put in your tea? Tea with milk and sugarDo you currently take any vitamin/mineral supplements? No.What is your height and weight? (PLEASE NOTE: This is for the Nutritionists, who will suspend reality if they ask you for this information. They will see it in the Student Instructions before seeing you.)5 feet 2 inches tall.155 poundsHave you noticed any recent changes in your body weight?I think I’ve lost a little bit of weight over the past two weeks since I fell and hurt my jaw.Questions about mood/depressionHow has your mood been lately? It’s okay. I’ve been kind of nervous over the past few months with all these falls. Sometimes I feel lonely and sad. Most of my friends have passed away and I don’t want to burden my family.Are you having anxiety/panic attacks? I get nervous that I might fall again. I worry a lot about my health and what will happen if I get sick. I don’t think I have panic attacks.Do you feel sad most of the time? No, just some of the time.Have you had previous mental health problems? No.Have you noticed any recent changes in your appetite? No, my appetite seems fine. I mean, I get hungry and I want to eat, but I am not eating as much due to my jaw pain.Any difficulty concentrating? No.How are you sleeping? Okay. Sometimes I worry and that makes it harder to sleep. I sometimes have burning pain in my feet that keep me up, but that’s rare.Questions about other geriatric issues:How is your memory? Pretty good. But sometimes I forget to take my eye drops or insulin.Do you have urinary incontinence/trouble controlling your urine? I can control my urine but I have to rush to get to the bathroom when I need to go. Do you have an Advance Care Directive? I don’t have one. Do you have a health care proxy or someone who will make medical decisions for you if you are unable to do so? No. I suppose my daughter would do it.GENERAL RULE OF THUMB: If the student asks a question that has not been addressed in these training materials, your answer should be “no,” (meaning that you have not had that symptom or problem). The student might ask you personal or social history questions that have not been addressed in these materials. In this case, you answer appropriately for the character you are portraying.DEALING WITH MULTIPLE QUESTIONS:If the student asks a compound question consisting of 2 questions (such as “Have you had chest pain or shortness of breath?”), you can answer BOTH questions, but must provide a clear answer for each component separately even if the answer for each is the same. In other words, do not just answer “No” to a compound question, say: “No, I haven’t had chest pain or shortness of breath.” If the student rattles off a list of 3 or more questions, answer only the last question asked (make it clear that you are answering only that one question). For example, the student may ask “do you drink alcohol, smoke, or use street drugs?”, in which case you would answer “No, I don’t use street drugs.”PHYSICAL EXAM:If the student rechecks your blood pressure, say to the student after s/he completes the maneuver, “You’ll find my current blood pressure reading in the top drawer.”Head, Eyes, Ears, Nose, Throat: You say the right eye is blurry but you can read at arm’s length and count fingers. Otherwise normal exam. Extraoral exam (outside your mouth): WNL, no asymmetries, no lymphadenopathies, no swelling. You have tenderness to palpation on right jaw.If the student says s/he would like to do an intraoral exam OR check your teeth and gums now OR look inside your mouth, reply, “You’ll find the dental exam results in the second drawer.”Physical Therapy ExamRight knee: The bruising on the right knee is gone. You can bend your knee to about 110-120degrees. You just report stiffness in the knee with range of motion. No pain.Standing Posture: your spine is curved so that you appear hunched overUpper and lower extremities range of motion:If you are asked to do any arm or leg movements, you are able to do most movements without complaining of pain. You have a little bit of groan at the very end of all your arm movements. (These are only age related groans).Strength: LEGS: If PT pushes leg or does any strength testing on the legs, you can slightly resist throughout the range of motion. Your leg strength overall will be a little bit weak. ARMS: You are able to resist all strength testing in your arms. GRIP: When PT asks you to grip their hands or fingers you do so without difficulty. Neurologic: Arm and leg reflexes are normal when the student uses a reflex hammer to testBoth legs have mild numbness/tingling/slight burning sensation in feet and just above ankle; Mild loss of sensation in the area of the lower leg/foot in the same area as it would feel if you were wearing a thin sock. If asked/tested, you can’t localize light touch well in your foot and slightly above ankle (where a dress sock would cover) and you guess location of light touch exam 50% correctly for both feet and ankles (PT will ask you to close your eyes and then will swipe parts of the leg to see if you can feel the touch or not.) Recommend you begin your answers to the sensation testing with “I think you touched my …”. You can guess the general area that the student touches but you are not able to specifically locate where they touched anywhere below the knees. Anything at the knee or above you can localize specifically. If student uses tuning fork to test for sensation in the sock area of your lower legs, you will say: “ I think I feel it, but I can’t say exactly where it is.” You do feel the vibration higher up. When the student moves your foot or leg in space and asks you if you can tell them if they have moved your leg or foot in space, reply: “I think you moved it up” (If they moved it up) OR “I think you moved it down” (if they moved it down). You will mostly want to be correct in your answers. Balance Testing: The Physical Therapy student will ask you to do some balance testing while sitting and standing. Any test they do while you are sitting—you are able to do without difficulty. When they ask you to stand up, you are able to stand up from the exam table with just a little bit of assistance using your arms to help you push up and stand up. You may have to try once before successfully arising (NOTE: because of time limitations in the encounter, this shouldn’t take an excessive amount of time). You tend to want to hold onto table etc. especially when you stand up for all your tests and measures with the PT student. However, when you are asked to walk, you do so tentatively on your own accord but hunched over and your walking speed is paced slow and you do not use an assistive device. You are tentative with walking since you don’t have anything to hold onto. If you are holding on to something (furniture, railing) you feel much safer. “I feel safe walking around my apartment when I hold onto the furniture.”When the PT tests your balance s/he may ask you to:Stand still with your eyes open and gently push you off balance -- YOU WILL BE ABLE TO STAND UPRIGHT WITHOUT FALLING. Stand on one leg OR stand as if you are on a tightrope with your eyes open--YOU CANNOT AND ARE TOO SCARED TO TRY!Stand still and close your eyes -- YOU WILL SWAY SLIGHTLY. Keep your eyes closed while s/he gently pushes you -- YOU’LL SAY, “I’M AFRAID I’LL FALL!” AND YOU WILL LOSE YOUR BALANCE BUT NOT FALL. Keep your eyes closed and stand on one leg—you can’t and you say, “ I’m certain I’ll fall.” Summary: You only feel safe when you are standing still and your eyes are open. Any other tests make you fearful of falling.Reach Test: Lateral/forward reach test: The PT may ask you to reach forward or reach to the side with your arm. You will be able to raise your arm but will be not be able to reach forward or sideways more than 1 inch. You are scared to do so. Coordination: (students are not likely to test coordination, but we included just in case) If the student asks, you can touch the tip of your finger to your nose normally. If the student asks, you can move your heel up and down your leg bone slowly and not precisely. Trunk Range of Motion: (students may or may not test) Bending forward, backward or side to side at the waist is limited whether standing or sittingYour fingertips are able to reach about halfway down to your knee. No pain. Twisting your body at your waist is limited whether standing or sitting.Straight leg raise: you can do but you say, “I feel pulling in the back of my leg.”Elsie Smith Life Events & Illness Timeline75 years ago (19__)Born in Oklahoma. Had an older sister.Over 60 years agoHad strep throat and allergic reaction to penicillin53 years ago ( 19__)Moved to San Francisco from Oklahoma at the age of 2251 years agoMarried your husband50 years agoGave birth to your daughter, Dorothy40 years ago Diagnosed with diabetes and started on oral medicationAt least 30 years agoDiagnosed in your 40’s with high blood pressure and high cholesterol. You take a water pill for the high blood pressure You don’t remember cholesterol drug.Years agoStarted having pain in your knees (arthritis). Told to take Tylenol and later Vicodin to help.Years agoNoticed numbness and tingling in your feet. Eventually prescribed Neurontin A little over 25 years agoDiagnosed in your late 40s with Glaucoma; noticed blurry vision in the eye that is the most affected by it. Prescribed Betaxolol & Pilocarpine23 years ago (19__)You quit smoking.20 years agoYou quit drinking alcoholOver 10 years agoLast visit to the dentist when you last remember having dental pain10 years agoHusband died of a heart attack5 years agoLast mammogram – normal resultsLast few yearsFeeling anxious about living alone and worrying about your medical problems and they prescribed LorazepamCouple of years agoMildred starting coming to help you 3 days a week.2 to 3 years agoWent to the eye doctor last time to have your glaucoma checked2 years agoSister , Georgia, died.Around a year agoLast doctor’s visit when he prescribed Lantus (insulin)Started to notice Dry Mounth symptomsA number of months agoRegularly walked a block to your corner store and went out to tend your plants.In the last several monthsStarted falling - you don’t remember exactly when or how many, once you tripped on the carpet, once; called a neighbor when your caregiver wasn’t thereTwo weeks agoWent to ER after your last; you hit your jaw and your caregiver could not get you up.Increased Vicodin to 2 tablets 2 times daily and continued Tylenol 2 tablets 3 times daily.During Last weekCaregiver wrote down your Monday Wednesday and Friday glucose readings on a piece of paper for youDecreased Vicodin to only 1 or 2 pills daily most of the time.NOWI’m scared of falling again; I’ve been falling too much. I also need to get refills of all my medications and get a new doctor .ELSIE SMITHINTRAORAL EXAM RESULTS Marked xerostomia with dry, cracked dorsum of the tongue and erythematous mucosa; poor oral hygiene.Periodontal Exam: generalized moderate periodontitis, with localized severe periodontitis. Class 3 mobility on #23-26, and Class 2 mobility on #31. Class 1 furcation on remaining maxillary molars and Class 3 furcation #31.Odontogram: no 3rd molars; missing #15,18,19,30; no partial dentures replacing missing teeth; several large restorations on her remaining teeth; caries under the margins of #31.Tooth vitality testing #31:PBM distal abutment crown of 3-unit bridge (#29-31), with extensive caries at the margins, extending up under the abutment crown; tenderness with buccal palpation; probing depths 6-9mm; Class 3 furcation buccal and lingual; fleeting pain to cold, pain with percussion on buccal cusps, electronic pulp testing is vital.ELSIE SMITHCURRENT BLOOD PRESSURE 152/89 ................
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