Somaticizing Patient - GLOWM



Lynn Jenkins

Facilitator Guide

Case Authors: Jacqueline Anne Bartlett, MD, Department of Psychiatry, NJMS

( 2006 Linda Boyd, DO, Department of Family Medicine at Medical College of Georgia

Revised: Neil Kothari, MD, Department of Medicine, NJMS

( 2010 Sophia Chen DO, MPH, Department of Pediatrics, NJMS

Primary Learning Objectives:

At the end of this case, students will be able to:

• Obtain a detailed medical history, including psychosocial aspects of the history, while expressing empathy and establishing rapport

• Develop a diagnostic work-up appropriate for a complex patient presenting with a vague and confusing history

Secondary Learning Objectives:

At the end of this case, students will be able to:

• Calculate a patient’s BMI in the office

• Select appropriate lab tests to screen a complex patient presenting with a vague and confusing history

Completed before case begins:

• Lectures delivered on history taking and the patient-centered interview

Recommended Readings:

• “5-Step Patient-Centered Interviewing” table adapted from Smith, RC. (2002). Patient-Centered Interviewing: An Evidence-Based Approach, 2nd Ed. Philadelphia: Lippincott Williams & Wilkins.

• Groopman, Jerome. (2003, August 11). Sick With Worry. Retrieved August 23, 2010 from “The New Yorker” website:

• Richardson, R.D., & Engel, C.C. (2004). Evaluation and management of medically unexplained physical symptoms. The Neurologist, 10(1),18-30. doi:10.1097/01.nrl.0000106921.76055.24 (Facilitators Only)

Homework assignment due at the next session:

• Write-Up of Lynn Jenkins’ medical history

Facilitator Notes: Overview

This is designed to be the first case of the Advanced Communication Skills course. As with all Problem Based Learning (PBL) cases, there will be opportunities to develop hypotheses for learning issues about a variety of medical illnesses, as this patient presents with a variety of symptoms. We do want to focus attention, though, to details of the development of a good doctor-patient relationship.

This case is intended to take 2 sessions. A student should be selected (volunteer or chosen) to assume the patient role if a Standardized/Simulated Patient (SP) is not assigned for that session. If a student is selected, s/he should be given the script that is included in the facilitator guide in advance.

Standardized Patient Vitals:

• A female patient (25-40 years old)

Symbols to help you navigate the facilitator guide:

1. No symbol before the bolded question means the question is for

small group discussions.

2. Student must interview the patient. (Different sections of the history can be performed be different students if the group has more than 5 or 6 students.)

3. Standardized Patient’s script

There will be learning issues as the case unfolds. Please have the students keep track of their own learning issues as they will need to research them and present their findings at the next small group session.

Overview of Case:

Lynn Jenkins is a 34 year old woman who appears anxious and worried. She presents to the family practice center with multiple physical complaints. After a normal physical examination and labs, the patient needs to be reassured that she is in good health. This is a case of a patient with medically unexplained physical symptoms.

Overview of First Session:

The goal of this session is to have the students obtain a full history from a standardized patient. It is expected that the students will develop learning issues relating to the case. Other crucial issues that will come up in this first encounter are effective ways of organizing an interview with a patient complaining of many symptoms involving multiple organ systems.

All students will need to submit a formal write-up of the medical history at the start of the next session, so please make sure they are scribing during this encounter. The student interviewing the patient should also be taking notes. This exercise will help them to identify any information that was missing from the SP’s history at the next session.

Standardized Patient’s Instructions:

Standardized patients are told that the facilitators will let them know how they will be used during the session(s). For example, you may choose to ask the SP to enter the room only when the students are instructed to interview him/her. You may ask the SP to leave the room and sit on a chair by the door for the remainder of the case. You may also choose to keep the SP in the room through the entire session, only asking him/her to speak during the SP activities. In addition, the SP should be encouraged to provide direct feedback to the students at the end of each session. The bottom line is the SP will play his/her role as instructed by the facilitator.

DISTRIBUTE STUDENT CASE PAGE 1

Scenario:

You are a student starting a clinical rotation at a family practice center. Your first day was just observation, but today Dr. Weston asks you to see a patient, Lynn Jenkins, whom he has seen once before. He asks you to do a complete history, because he didn’t have the time to do it at the last visit.

What do you do first?

Facilitator Notes:

Students might discuss reviewing the medical record or the history-taking section of their textbook before entering the room. They should also discuss the proper etiquette for entering the exam room and initiating the interviewing process.

Prompting Questions which can be used to facilitate this discussion include:

1. Is it better to review the chart first?

2. Discuss the pros/cons of reviewing the chart before interviewing the patient.

a. Pros: Patients appreciate you knowing their story and context without having to repeat it all the time

b. Cons: Looking at a patient (especially someone with complex problems) with fresh eyes can be an advantage, but still need the old records at some point.

3. What is the best way to enter the patient’s room? (Knocking first, etc.)

4. How should you introduce yourself as a student?

Room Setup/Guidelines:

Arrange the room so the standardized patient (SP) can sit at the front of the room and have one other chair for students to take turns as they assume the role of the health care professional asking questions.

Only the SP and the facilitators have the full history information. The students will not get this information until later unless they specifically ask the SP the appropriate questions.

Feel free to prompt the students if they get stuck during parts of the history. This session will serve as a time for them and you to assess their current levels of knowledge and skill at basic history taking while establishing rapport. Other students can be asked to make suggestions before the facilitator does.

Small Group Assignment: Students should scribe the history obtained from the SP on a sheet of paper. The student who is interviewing should also take notes. A formal write-up of the medical history must be submitted at the start of the next small group session.

Select a student to begin taking the history from Ms. Jenkins.

Facilitator Notes:

At this point, the student eliciting the history might panic and not know which direction to take the interview given the number of complaints. Let them struggle a little on their own. At some point you can take a time out and discuss some strategies for this situation.

Options for approaching this scenario:

1. Can take a complete History of the Present Illness (HPI) for each complaint (takes a lot of time)

2. Can try to take the HPI all together, trying to figure out where each symptom came in and if they are related (more efficient, but can be very confusing)

3. If some symptoms seem to be independent and unrelated, then can take a separate HPI for those symptoms (students may find it difficult to determine whether something is related or independent this early on)

SP NOTES

Lynn Jenkins is a 34 year old female

SIMULATED PATIENT– You should look wide-eyed at the student doctor (to convey moderate anxiety) and speak a bit quickly. Should appear in mild distress and act slightly annoyed if the student doctor tries to pin you down to be very specific about your symptoms. Ask the student doctor every so often what they think is wrong with you. “Will I be all right?”

(Give brief answers, which are SPECIFIC to any question asked. Stop until asked more questions. Do not volunteer any information regarding anything not asked by the person interviewing you. Make it difficult, but not impossible. Be upset if the questions are repetitious.)

CHIEF COMPLAINT: “I feel yucky almost all the time. I am tired, my back hurts, I get headaches and sometimes my stomach is upset. I even feel nauseous.”

HISTORY OF PRESENT ILLNESS: Fatigue, back pain, headaches, nausea, upset stomach for past 6 months

You have had all of these symptoms for 5 to 6 months. Symptoms are getting worse.

Tired most of the time.

Headaches are at both temples and throbbing in nature, sometimes includes neck pain. Sleeping or rest makes them better. (stop) Sometimes Advil® helps.

The low back aches almost all the time. No radiation of pain to any where else. Located in lumbar region. Nothing except Advil® or rest makes it better. You do not take anything else for this symptom now (over-the-counter or prescribed).

Everything is so bad that now it interferes with taking care of home and kids. (stop)

Feel drained all the time now and have started to miss work. (stop)

When asked specific questions about each symptom, be simple.

For example, if asked, “Is there anything that makes the nausea worse or better?” Answer, “not really, sometimes TUMS® or ginger ale helps”. No vomiting. Some increase in appetite and weight (2-3 lbs)

If asked how bad the symptom is on a scale of 1-10, answer “6 or 7.”

Facilitator Notes:

At various points while the student is taking the History of Present Illness (HPI), ask why he/she is asking specific questions. For example:

Prompting Questions:

1. Why is it important that you are asking what the character of the back pain is? What does dull back pain mean vs. sharp back pain?

2. Is acute back pain different from chronic back pain? How?

3. At the end of the HPI, stop the student taking the history and ask the group to begin to develop ideas about what might be wrong with this patient (differential diagnosis.)

4. Can these symptoms possibly make sense as a single disease?

5. Write the hypotheses/ diagnoses on the board.

Prompting Relationship-developing Questions:

At any point in the history, stop the interview and ask:

1. What did the patient say that made you ask this question?

2. Why did you ask it now?

3. How does this question help you to develop the differential diagnosis?

PAST MEDICAL HISTORY:

Hospitalizations: Hospitalized for childbirths x 2

Surgeries: 2 Caesarean sections

Tonsillectomy age 7

Childhood Illnesses: None

Injuries: Broke wrist falling down stairs at school 18 years ago

Past Illnesses: Weight problems in adolescence (was obese), but lost weight in college.

Had mono age 18

History of mild anemia in past

History of positive Lyme test done after had rash on leg and knee pain, treated 2 years ago. No further joint problems

GYN: Started periods at age 14. Periods are regular every 28-29 days, lasting 5-6 days with heavy bleeding the first 3 days.

2 pregnancies, full-term deliveries delivered by C-section due to the fact that both babies were too large to be delivered vaginally

Had a tubal ligation with the last C-section.

Psych: Denies being depressed , down or nervous. Never had any psychiatric illness. Never saw a therapist or psychiatrist.

Transfusions: None

Meds: Takes multivitamins. Does not know if takes iron in her multivitamin.

Takes Echinacea for colds. Last time was 3 weeks ago.

Tried “everything” for the symptoms in the past and only Advil® works sometimes. Only give specific medicines if asked about over-the-counter medications.

-Tylenol®, Excedrin® & Advil® for headaches

-TUMS® for stomach upset

Takes her husband’s codeine very rarely maybe once or twice a month.

Allergies: None

FAMILY HISTORY:

Both parents alive and well (m=60, f=62)

Mother had Hashimoto’s thyroiditis in past

Father has mild hypertension on atenolol, and hyperlipidemia on rosuvastatin

Kids healthy, oldest has mild asthma

Paternal Grandmother (PGM) died of stroke at 65 y/o

Paternal Grandfather (PGF) died of MI at 60 y/o (both died during her childhood - had been close to them)

Maternal Grandfather (MGF) in nursing home with Alzheimer’s Dementia

Maternal Grandmother (MGM) is 80 lives alone. Has type II diabetes mellitus. Doing OK on oral meds. Still obese.

Has 3 siblings, she is 3rd of 4 girls, all alive and well. All married and work outside home; oldest is lawyer, next sister is nurse, and youngest is lab tech at same hosp as sister #2. All deal with weight problems.

CURRENT HEALTH/RISK FACTORS:

Exercise: Occasional, but usually too tired now

Used to walk/hike regularly

Nutrition: Healthy, low-fat diet, no meat except occasional chicken

Tends to eat too many sweets (especially chocolate)

Smoking: Never smoked

Alcohol: Wine after work daily. 1 glass or so most days helps her relax and get to sleep. Never gets drunk. (If asked the CAGE[1] questions: has not cut down her drinking, no one has been annoyed at her drinking, she feels guilty about drinking with her kids around, she has never had an eye-opener)

Drugs: Never

Sleep pattern: Trouble sleep onset many nights, some middle of night awakening with trouble falling back asleep. Gets up to not disturb spouse. Wakes up feeling tired. Usually sleeps 6-8 hours.

Recent exams: Last physical exam here 2 months ago. Here for complaints of no energy. She was told there was nothing wrong. Vitamins and rest were recommended.

Had GYN exam 6 months ago with a different doctor. Had upper GI series in past year ordered by another doctor. Was tested for Epstein Barr Virus & mononucleosis 1 year ago. Also tested for thyroid problems last year by her previous doctor. Changed doctors because they kept telling her there was nothing wrong.

Immunizations: Up to date

Injury prevention: Uses seat belts, no high risk activities etc.

SOCIAL HISTORY:

Personal Status: Lives with husband (married for 10 years) and two children, 6 & 8. Youngest started school last fall, now in first grade. Oldest child is good student, but child worries about schoolwork. Some financial concerns, she needs to go back to work full-time.

Culture & Religion: Raised Protestant, but not very religious. Only attends church occasionally on holidays. Caucasian [or insert SP’s race if different], 1st generation American. Parents emigrated from the former Czechoslovakia during the Communist rule.

Support system: Some friends, but mostly stays home with kids. Marriage is OK. Husband works a lot and commutes to the city daily. Her Mom is supportive and is the only outside child-care they have had.

Socioeconomic: Has good health insurance

Domestic Violence: Denies. If asked the HITS[2] questions specifically: husband has never hit her, never insulted her, never threatened her with harm, but has occasionally yelled at her as she does to him. Children disciplined with time out, sent to their room, or loss of privileges. She does tend to yell at them a lot.

Occupation: College grad, studied business/finance

Education: Worked part time as bank teller for past year.

Worked full time in bank as teller age 20 to 22 then as asst. loan officer age 22 to 26 (birth of first child). Was homemaker for 7 years after babies were born.

Sexual Behavior: First intercourse at age 20. Total of 2 male partners. Vaginal intercourse only. Current sex life is ‘nonexistent’ if asked more, gets defensive and asks how this matters. Has lost interest lately

Military: None

Travel: Was in Puerto Rico with spouse for vacation 6 months ago (if asked about travel)

REVIEW OF SYSTEMS: (info given only if you are asked about each system)

General: Gained some weight with babies, and has maintained current weight since her last baby. Knows she should lose about 15 lbs

Heent: Occasional stuffy nose

Pulmonary: Occasional cough

Heart: Occasional fast beats

GI: No diarrhea or abdominal cramping

GU: Occasional urinary frequency

Neuro: Occasional tingling in feet

Musc-Skel: Per HPI. Denies sensory loss

Psych: Tends to worry, especially about health of self, kids and spouse

occasional feelings of faintness/dizziness.

Denies depression or anxiety, but acknowledges worries and stress. Was good student in school, but always very anxious about tests and presentations. Feels guilty she cannot work now felt guilty about being at work when kids were home (eg. school holidays)

DISTRIBUTE STUDENT CASE PAGE 2

Now that you have taken the complete history, what problems have you identified with this patient?

What are the hypotheses/ differential diagnoses for the problems that you have identified?

Facilitator Notes:

Hand out the VINDICATE SLEEP[3] mnemonic for use with generating hypotheses,

Some of the diagnoses the students may be considering at this time are:

• allergies ( sleep apnea

• iron deficiency anemia ( premenstrual tension

• anxiety ( chronic fatigue syndrome

• depression ( tension headache

• insomnia ( migraine syndrome

• hypothyroid ( systemic lupus erythematosis

• diabetes mellitus ( fibromyalgia

• chronic Lyme disease ( chronic pyelonephritis

• gastritis ( hepatitis

After the group generates a differential, hand out the Sources for Learning Issues in Problem

Based Learning Grid sheet to students. Each student will need to use a variety of resources in researching learning issues during the course, and turn in the completed sheet to the facilitator during the last small group session.

Prioritize the hypotheses based on what problems you know so far.

Learning issues can include expanding knowledge of the group about each illness listed in the differential diagnosis to further guide the evaluation of this patient at the next session. Use of multiple information sources is encouraged. Consult senior students, residents, attendings, as well as reference materials. Students should document their sources on the grid provided to them.

HOMEWORK ASSIGNMENT: Submit a formal write-up of Lynn Jenkins’ medical history to your facilitator at the start of the next small group for grading.

Also, students should prepare to recommend a treatment plan to this patient with medically unexplained medical symptoms at the next session.

END OF SESSION 1

LYNN JENKINS – SESSION 2

Overview of Second Session:

During this session, the students will need to elicit a focused history, discuss lab results, and recommend a treatment plan to a standardized patient with multiple unexplained physical symptoms.

Facilitator Notes – Overview and Student Presentations

1. Have each student give a 2-3 minute presentation on their learning issues. Remind students to keep track of which resources they use each week on their PBL grid.

2. After the learning issues are presented, have one student summarize the case.

3. Collect the homework assignment from the students.

4. The group should then re-evaluate and prioritize their hypotheses based on the new knowledge from the presented learning issues.

DISTRIBUTE STUDENT CASE PAGES 3-6

Here is the complete history from Lynn Jenkins:

HISTORY OF PRESENT ILLNESS:

She has had all of these symptoms for 6 months. Symptoms are getting worse. Headaches are at both temples and throbbing in nature. Sleeping makes them better.

The low back aches all the time. Nothing makes it better or worse, except rest. She takes no meds now for her symptoms, but has taken various over-the-counter (OTC) meds in the past. She saw this doctor for these same problems several months ago and saw previous doctors for these symptoms multiple times in the past several years.

Everything so bad that now it interferes with taking care of home and kids

Feel drained all the time now and has started to miss work, also.

The symptoms on a scale of 1-10, are “6 or 7”.

PAST MEDICAL HISTORY:

Hospitalizations: Hospitalized for childbirths x 2

Surgeries: 2 Caesarean sections

Tonsillectomy age 7

Childhood Illnesses: None

Injuries: Broke wrist falling down stairs at school 18 years ago

Past Illnesses: Weight problems in adolescence (was obese), but lost weight in college.

Had mononucleosis age 18, out of school for 3 months

History of mild anemia in past treated with multivitamin and iron, never

worked up for other causes of anemia. Lyme disease treated 15

months ago

GYN: Menarche at age 14. Periods regular every 28-29 days, lasting 5-6 days with heavy bleeding the first 3 days. 2 pregnancies, full-term deliveries delivered by C-section. Had a tubal ligation with the last C-section.

Used birth control pills prior to that

Psych: Denies being depressed, down, or nervous. Never had any psychiatric illness. Never saw a therapist or psychiatrist.

Transfusions: None

Meds: Takes multivitamins. Admits to not taking them regularly. Does not know if

she takes iron in her multivitamins now.

Takes Echinacea for colds. Last time was 3 weeks ago.

Tried “everything” for the symptoms and nothing works. Only give specific medicines if asked about over-the-counter medications.

-Tylenol®

-Advil®

-TUMS®

-Pepcid AC

-Excedrin®

-Husband’s codeine occasionally

Allergies: None

FAMILY HISTORY:

Both parents alive and well (m=60, f=62)

Mother had Hashimoto’s thyroiditis in past

Father has mild hypertension on atenolol, and hyperlipidemia on rosuvastatin

Kids healthy, oldest has mild asthma

MGM died of stroke

PGF died of MI (both died during her childhood - had been close to them)

MGF in nursing home with Alzheimer’s disease

MGM is 80 lives alone. Has type II DM. Doing OK on oral meds. Still obese.

Has 3 sibs, she is 3rd of 4 girls, all alive and well. All married and work outside home

oldest is lawyer, next sister is nurse, youngest is lab tech at same hosp as sis #2. All deal with weight problems.

CURRENT HEALTH/RISK FACTORS:

Exercise: occasional, but usually too tired now

Before marriage went to health club or exercised regularly with friends

Used to walk/hike (was in sierra club)

Nutrition: healthy, low-fat diet, no meat except occasional chicken, chocoholic

Smoking: never smoked

Alcohol: Wine after work daily. 1 glass or so most days helps her relax and get

to sleep. Never gets drunk. If asked the CAGE questions: has not cut

down her drinking, no one has been annoyed at her drinking, she

feels guilty about drinking with her kids around, she has never had

an eye-opener)

Drugs: Never

Sleep pattern: Trouble sleep onset many nights, some middle of night awakening

with trouble falling back asleep. Gets up to not disturb spouse. Wakes up

feeling tired. Usually sleeps 6-8 hours

Recent health exams: Last physical exam here 3 months ago. She was told there

was nothing wrong. Vitamins and rest were recommended. Had GYN exam 6 months ago. Had upper GI series in past year. Was tested for EBV & mono >1 year ago. Also tested for thyroid problems last year. Changed doctors because previous doctor kept telling her there was nothing wrong.

Immunizations: Up to date

Injury prevention: Uses seat belts, etc.

SOCIAL HISTORY:

Personal Status: Lives with husband (married for 10 years) and two children, 6 & 8.

Youngest started school last fall, now in first grade; oldest good

student, but a bit nervous about school

Culture/Religion: Raised Protestant, but not very religious. Only attends church

occasionally on holidays.

Support system: Some friends, but mostly stays home with kids. Marriage is OK.

Husband works a lot and commutes to the city daily. Mom is

supportive and is the only outside child-care.

Socioeconomic: Has good health insurance

Domestic Violence: Denies. If asked the HITS questions specifically: husband has

never hit her, never insulted her, never threatened her with

harm, but has occasionally screamed at her.

Occupation: Works part time as bank teller for past year. College, majored in

business/finance. Worked in bank as teller age 20 to 22 then as

asst loan officer age 22 to 26 (birth of first child). Was homemaker

for 7 years after babies were born.

Sexual Behavior: First intercourse at age 20. Total of 3 male partners. Vaginal

intercourse only. Never used condoms. No history of STD. Used

birth control pills initially after marriage. S/p tubal ligation.

Military: None

Travel: Was in Puerto Rico with spouse for vacation 6 months ago

REVIEW OF SYSTEMS:

General: Gained some weight with babies, but has maintained this weight

since her last baby.

HEENT: Occasional stuffy nose

Pulmonary: Occasional cough

Heart: Occasional fast heartbeats

GI: No diarrhea or abdominal cramping

GU: Occasional urinary frequency. Last menstrual period (LMP) started 3 days ago

Neuro: Occasional tingling in feet

Musc-Skel: Per HPI, sensory intact

Psych: Tends to worry, especially about health of self, kids and spouse

Occasional feelings of faintness/dizziness. Denies depression or

anxiety, but acknowledges worries and stress. Was good student

in school, but always very anxious about tests, and presentations.

Conflicted about working, especially when kids on holiday from

School

Discuss each question one at a time……

1. What additional problems do you see from this history?

2. What are the gaps between this information and the history our group obtained initially?

3. Why do you think you missed some information?

4. How could you ask questions differently next time, so you can get more accurate information?

5. Are there any additional hypotheses with the new information, or any that can be deleted?

6. What do you do now? Why this path?

Facilitator Notes:

Be supportive of your students if they did not gather all the information. Help them to realize that this patient has a lot of symptoms and was not forthcoming at giving specific information. It’s usually easier to get to know patients better over time. It’s normal for a patient not to reveal everything the first time he/she meets a health care professional.

Some suggestions for the group (if they did not gather large parts of the history) are to be more emotionally supportive of the patient, and to be careful with phrasing of questions.

Prompting Questions:

1. How does it feel to take a history from this patient?

-Common reactions to this kind of patient would be frustration, confusion, feeling inadequate with your skills.

-Desire to reassure the patient.

DISTRIBUTE STUDENT CASE PAGE 7

You have completed the history and you present to Dr. Weston. He tells you that he appreciates the time you spent with her and shares that he was frustrated at the last few visits with her because he too was unable to determine a specific medical cause for her symptoms.

He suggests that you both go back in and perform a physical exam.

Vitals: Height 5’5” Weight 172 lbs

Temp 98.6 Blood pressure 130/80 Pulse 84 and regular Respiratory Rate 20

General appearance: Well developed, well nourished, in some apparent distress, somewhat pale

HEENT: Pupils equal round and reactive to light, extraocular movements normal, tympanic membrane normal bilaterally, good dentition, pharynx/tonsils normal

Neck: Thyroid palpable with no enlargement, nodules, or tenderness. No cervical nodes palpable. Full range of motion

Heart: Regular rate and rhythm, no heaves, murmurs, rubs or gallops

Lungs: Clear to ausculation, normal percussion

Abdomen: Slightly protuberant, normoactive bowel sounds x 4, no tenderness, no enlarged organs or masses, + semi-lunar scar above pubis

Extremities: Full range of motion, no joint swelling, no tenderness, erythema or deformities

Mental Status: Orientated x 3, memory intact, slightly anxious mood/affect

Skin: No rashes

Neuro: Deep tendon reflexes +2/4 bilaterally, muscle strength +5 all extremities, all cranial nerves intact

What problems did you identify during her physical?

What is her BMI? Why does this matter?

What are your Differential Diagnoses (hypotheses) now?

|Facilitator’s Notes: |

|The BMI (Body Mass Index) is an indicator of weight status that is commonly used. This patient’s BMI is 28.7 |

|Metric Imperial BMI Formula |

|The metric BMI formula accepts weight measurements in kilograms & height measurements in either cm's or meters. |

|1 meter = 100cms |

|meters² = meters x meters |

| |

|BMI = weight in kilograms / height in meters2 |

| |

|BMI |

|Category |

| |

|< 18.5 |

|Underweight |

| |

|18.5 – 24.9 |

|Normal |

| |

|25 – 29.9 |

|Overweight |

| |

|≥ 30.0 |

|Obese |

| |

| |

|Students should use this as a learning issue if they do not know the calculation. They should also research quick and easy ways for practicing |

|physicians to determine patients’ BMI’s: |

|BMI calculator wheels |

|Electronic medical record automatically calculates for you |

|EBM calculator on PDA or Smart Phone |

Facilitator Notes:

Some of the diagnoses the students may be considering at this time are:

• allergies

• iron deficiency anemia

• chronic Lyme disease

• anxiety

• depression

• insomnia

• hypothyroid

• diabetes mellitus

• gastritis or other inflammatory process

• hepatitis or other chronic infection, such as chronic pyelonephritis

• neoplasm

DISTRIBUTE STUDENT CASE PAGE 8

What lab tests or other diagnostic studies would you like to order? (You must give justification for each test.)

Facilitator Notes:

Ask the students if they would prefer to get old records before ordering the tests.

The following lab tests might be ordered:

• CBCD (Complete Blood Count with Differential) - to rule-out anemia

• Urinalysis and/or urine culture – to rule out chronic infection or renal disease, also can screen for elevated bilirubin

• Fasting Blood Sugar – to rule out diabetes, glucose tolerance issues

• Lipid profile – as part of adult health screening (should be fasting) – Do you only do this for overweight and obese patients?

• TSH (thyroid stimulating hormone) – to rule out thyroid disease, especially hypothyroidism in the setting of positive family history

• ANA (anti-nuclear antibodies) – screen for inflammatory conditions such as lupus

• ESR (Sedimentation Rate) – a non-specific screen for inflammation

• C-reactive protein (CRP) – a non-specific screen for inflammation

• Hemoccult® – test for blood loss, as from ulcer or gastritis, and colon cancer

• LFTs (Liver Function Tests) to rule out liver disease (eg hepatitis) or Tylenol® toxicity

What would you tell the patient at the end of her first visit before she goes home?

Facilitator Notes:

1. If you are not sure what’s wrong yet, how do you say you do not know?

2. Do you say “nothing is wrong” to someone who feels so poorly?

Most physicians would reassure Ms. Jenkins and tell her that her physical was essentially normal. The only problems found are that she was slightly overweight, but not at a level that should cause significant health problems. Her blood pressure is also slightly elevated.

Prompting Questions:

1. Would you even discuss Ms. Jenkins weight as a problem?

2. What wording would you use to describe her weight?

3. Does your wording choice make a difference?

4. Does she have hypertension? How does one make the diagnosis?

DISTRIBUTE STUDENT CASE PAGE 9

Ms. Jenkins is advised to return to the office in two weeks. She is told that you will call her when the labs are back. Five days later though, Ms. Jenkins returns to the office and Dr. Weston sends you in first. He tells you that she called the office at least 4 times asking for her lab results, beginning the morning after her last visit. The office staff said that she was quite rude and upset the last time when she was told that the doctor would call if there was anything abnormal.

What do you do now?

Select student to go into the room to take the history.

Facilitator Notes:

Arrange the room as last session and continue role-playing, taking turns with the students playing the health care professional. Be aware that all students must take a turn and keep track of who interviews during each session. Students should review the labs before they begin the encounter, but if they forget and do not, then allow them to go in without reviewing them, and discuss later.

SP Notes:

When asked how she is feeling, she responds that she is worse and is really worried.

Feeling lightheaded now.

All the other symptoms are worse, too.

She then interrupts and asks about her lab results: “Are they back?”, and “What is wrong?”

“Is there any medicine that will help me?”

(If asked, she has cut down drinking.)

She is sleeping more and wants to go to bed as soon as she gets home.

Her husband is coming home earlier so that he can make dinner for the family. He is worried about her.

Facilitator Notes:

Prompting Questions:

1. What do you do now?

2. How do you respond to her concerns?

3. What do you think Dr. Weston can/should say to her?

DISTRIBUTE STUDENT CASE PAGES 10-11

You present the history to Dr. Weston and you both go in to do a physical exam.

T = 98.6 P = 92 BP 128/80

Pt more openly acknowledges being worried throughout the physical.

Physical exam is again completely normal, except for weight down to 168 lbs.

Labs are back:

CBCD: White Blood Cell (WBC) count 6.8 T/ul with a normal MCV, Hemoglobin 11.0 gm/dl (reference range 12-14 gm/dl), Hematocrit 32%

Fasting blood sugar: 96 mg/dl

Total cholesterol: 186 mg/dl, HDL: 50 mg/dl

LFT’s: normal except for mildly elevated AST at 45 (normal is 0-40)

TSH: 2.3 uu/ml (reference range 0.27-4.0 uu/ml)

UA: occasional WBC, trace protein, trace blood, 5 squamous epithelial cells present

Hemoccult®: negative for blood in stool

ANA: negative

Sedimentation rate: high normal range

C-reactive protein: normal range

Can you eliminate any of the hypotheses from your list based on this information?

What will you tell the patient?

Select Student to speak with the standardized patient, Ms. Jenkins.

SP Notes:

Patient is reassured by the doctor that nothing seriously wrong with labs and on PE.

If the doctor tells you that the only abnormal thing they found is that you are a overweight and suggests a diet, you should get angry and respond with something like, “Look, I have struggled with my weight all my life. I know I am a little overweight, but I have a very healthy diet and I used to exercise regularly, so I don’t know what you expect me to do. If I were eating poorly or sitting around never moving my body, I could accept that I need to do something more about my weight, but I cannot believe that a few extra pounds is causing me to feel nauseous and tired all the time.”

Act worried and anxious. Repeat that you know something is wrong. You need a doctor who is going to believe you and find out what is wrong. Convey that worry by asking for more tests and saying that you are sure something is very wrong.

Facilitator Notes:

Once the SP conveys worry and anger to the doctor, take a time-out and ask the student how he/she is reacting to this situation.

• Ask the group how they are feeling and what they are thinking about the patient.

• Talk about how you can manage a patient who is reacting with anger and challenging what you are suggesting.

• Facilitators should use the MUPS paper for background reference in preparing for this discussion

Facilitator Notes:

When a patient confronts you with wanting more tests, it is likely to make the doctor uncomfortable.

To start with, the student can help the situation by addressing her concerns directly. Empathic statements like, “I can see that you are very worried about your condition” can give the patient an opportunity to discuss her worries and fears and diffuse some of her anxiety.

Would you order more tests?

If so, which ones? (You must justify them.)

Facilitator Notes:

Some tests the students might consider:

• MRI – to evaluate headaches and address her concern of brain tumor – very expensive. Hard to get insurance authorization without extensive history. If you are doing it to calm the patient, then perhaps a CT scan would be better – cheaper and easier to order.

• Fundoscopic exam – reasonable to perform since her headaches have increased looking for papilledema (swelling of the optic disc).

• Prolactin level – increased prolactin can come from a pituitary tumor in the midbrain, which could cause headaches. She has no other symptoms of pituitary tumor, though.

• Upper GI series – to look for esophageal/gastric tumor or ulcer (has a likelihood ratio of 11 vs. endoscopy with a likelihood ratio of 41 – i.e. endoscopy is a better test.)

What are some other ways that you can make Ms. Jenkins feel better, other than ordering tests?

Facilitator Notes:

• Acknowledge her grave concerns

• Schedule time to talk with her – frequent follow-ups

• Refer to psychologist – this is really important, but it has to be handled sensitively. You don’t want the patient to get the impression that you are saying that her symptoms are “all in her head.”

• Refer to a colleague or specialist – this is “turfing” the problem and will not likely make her feel any better, since there is probably nothing physically wrong. The specialist probably has less time and less training in dealing with these problems, as compared to the primary doctor.

How will you sleep at night without doing any tests?

You and Dr. Weston go in the room and he repeats the physical exam concurring with your findings.

As a group, you should decide how you are going to advise Ms. Jenkins.

Select Student to give the advice to your standardized patient, Ms. Jenkins.

SP Notes:

If the doctor suggests a referral to a psychiatrist, react according to the way he/she says it. If it is done sensitively letting you know that physical symptoms can be caused by emotional or mental stress, then you should be rather accepting and calm about this referral.

If the doctor suggests a referral to a psychiatrist because there is nothing physically wrong (meaning the problem must be psychiatric), you should react as if you are offended and angry.

If the doctor suggests that you see another specialist, you should be pleased with that referral, but still act worried about your problem. Ask the doctor if you are supposed to still see him/her, too, or just the specialist. If he/she suggests that you transfer care to the specialist, then act very upset. Say something like, “I feel like I’m just getting shoved off to another doctor.”

What is the likely outcome with this patient?

Facilitator Notes:

Somatizing (MUPS) patients often experience primarily the physical aspects of emotions and are challenging to investigate. The doctor needs to be comfortable with the patient’s anxiety, anger, and dissatisfaction at times. The relationship and trust are key. If the patient knows that your goal is to help them feel better (which does not necessarily equal ordering more tests, giving more medicine, sending for referrals) and that you will stick with them, then you have a good chance of not only helping the patient to feel better, but helping the patient avoid unnecessary treatments and procedures that could be harmful.

Many patients with somatization engage in “doctor-shopping”. Realize that this might happen from time to time, especially if they are feeling bad and you are not ordering tests – they might get very anxious or go to someone else.

END OF CASE

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[1]Ewing, J.A. (1984). Detecting Alcoholism: The CAGE Questionnaire, Journal of the American Medical Association, 252: 1905-1907.

[2] Sherin KM, Sinacore JM, Li XQ, Zitter RE, Shakil A. (1998 Jul-Aug). HITS: a short domestic violence screening tool for use in a family practice setting, Family Medicine, 30(7): 508-12.

[3] Collins, R.D. (1981). Differential Diagnosis in Primary Care. Philadelphia: J.B. Lippincott Company.

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