Training and Using Standardized Patients for Teaching and ...



Case Blueprint: Team 4Case Name:Norma Nelson-Chronic pain with comorbid mental health disorderPresenting Complaint:Norma Nelson, age 27, presents to the clinic with abdominal pain for 9 months. Vitals: 138/85; Pulse 92; RR 16; T 97.9FGender and Age:Female; 27 years.Key Objectives:Identify the comorbid mental health disorder as a contributor to the complexity of management of the chronic pain complaint.Brief Case Summary:Chronic abdominal pain with no obvious pathology/disease. Started while in the National Guard during deployment to the Middle East. No associated nausea, vomiting, diarrhea or constipation. No urinary symptoms. No gynecologic or obstetrical symptoms. History of sexual assault by a superior but not reported (not volunteered unless asked). Having flashbacks, nightmares, social isolation, fatigue, panic attacks, blunted affect developing over the last six months (not volunteered unless asked).No surgeryNo significant injuries or illnessesTaking over-the-counter analgesicsDifferential Diagnosis:(diagnosis in parens)(Post-traumatic stress disorder)DepressionSomatizationPelvic inflammatory diseaseTask(s) for Examinee:Obtain a history and perform a physical examinationExam Room Needs: Patient in a gown.Presenting situation and checklistsPost-Encounter Station Needs: Pen and paper; place for writing.Data Collection Tool(s):SP checklistDesigned for:Internal medicine residents and second-year physician assistant studentsCase Authors:Tina WhiteSilvia WanagatMelissa KingJohn LopesDate:April 28, 2017SP Training Notes: Team 4Case NameNorma NelsonPresenting SituationNorma Nelson, age 27, presents to the clinic with abdominal pain for 9 months. Vitals: 138/85; Pulse 92; RR 16; T 97.9FStudents will do a history and physical examination appropriate for the patient’s problemsPsychosocial ProfileChronic pain with associated mental health disorder.You are dressed in an examination gown with a blunted affect and are cooperative with the examiner but not very forthcoming with information unless asked specifically. You are seated on the table physically withdrawn. You are frustrated with the inability of previous providers to define a cause for your pain. You are not hopeful that this examiner will be more successful. You are anxious about this encounter due to the lack of previous success in determining a cause for the pain.Not to be disclosed unless asked specifically:You were the victim of a sexual assault by a superior while serving in the National Guard in Afghanistan. You did not report the assault. The following started around a month after the assault: You are having panic attacks when around groups of men, flashbacks to the assault, nightmares. The abdominal pain started around the same time.Due to all the media attention to sexual assault and post-traumatic stress disorder in veterans you are thinking this might be related.Opening Statement“My stomach has been hurting and no one has helped me”.Statement Elaboration to open-ended question“This has been going on for so long and nobody has figured out what is going on. I just want to get something to make me better”.History of Present IllnessChronic lower abdominal pain for the last 9 monthsStarted while deployed to Afghanistan with the National GuardPain located mostly on the left sidePain is dull and achy and constantPain scale: typically, 3-4/10 with occasional increase to 6/10Nothing so far has helped-tried ibuprofen and naproxen without reliefPain medicine the Army doctors gave me made me sickSeems to get worse with walkingIf asked whether the pain interferes with sleep: “Not the pain”Getting about 4-5 hours of sleepGoes to bed around 11 amIt’s there when you go to bed and when you wakeNo radiationNo nausea, vomiting, change in bowel habitsNo urinary symptomsNo vaginal dischargePeriods normalNo symptoms of pregnancyYou have had abdominal scans done in Army hospitals with no diagnosis made.Not to be volunteered unless specifically asked:NightmaresFlashbacks to sexual assaultPanic attacksTrouble falling asleepDay time sleepinessPast Medical HxNo serious illnesses or injuriesNo operationsHas intradermal contraceptive implant (Implanon) placed two years agoImmunizations UTDNo pregnancies/childrenSocial HxNo tobaccoTwo or three beers/glasses of wine to help you sleep (CAGE response: No)No illicit drugsSingleYou are a truck driver in a transportation company in the Illinois Army National GuardUnemployed: you lost your job in retail sales while deployed in AfghanistanYou returned to Illinois 6 months agoLiving with your mother (good relationship with your mother) father lives out of state; no siblingsFamily Medical HxNone significantPhysical Exam Findings:Physical examination normal.Special Instructions:You will not be forthcoming with information and will provide short answers to questions. You will provide information on symptoms associated with PTSD when asked more specifically and the student demonstrates empathy. You are motivated to find a cause for your pain. You expect to be taken seriously by your doctor. You will be annoyed if it is not. PRESENTING SITUATION: Team 4Patient Name (with age):Norma Nelson, 27Setting:Outpatient clinic officeVitals:Temp97.9FRR16BP135/85HR92Complaint:Patient complains of abdominal painYou have 15 minutes to complete a focused history and physical exam, and to discuss your findings and plan with your patient.* After you are finished with your patient, please return to the front of the PDL, where you will complete a written follow-up. * H&P Checklist for:_Chronic pain with comorbid mental health disorder (Team 4)Date_________Student_______________________________SP initials_______YesNoIntroduces selfConfirms patient identitySolicits chief complaintComments on your demeanorAsks about effect of pain on sleepAsks follow-up questions regarding sleep disturbanceWhy is sleep disturbed?Asks questions regarding symptoms associated with PTSDNightmaresFlashbacksPanic attacksSolicits history of sexual assault as cause of PTSDOffers referral to counselor/psychologist/psychiatristOffers referral to sexual assault counseling serviceExplains follow up plans and treatment planComments or Clarifications: Post-Encounter Station for Student/Examinee: Team 4Case Name: Norma NelsonDirections to Student: Please write a SOAP note on this patient.*Student name: ______________________________Date: ____________ ................
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