CAE LearningSpace™ - Case Manager
Sample Case Kelly Jackson (Fatigue)
Pre-Encounter Learner- WHAT THE STUDENT WILL SEE
Patient Information (Door Info)
Information for the StudentPatient Name: Kelly Jackson
Age: 45
Setting: Medical Clinic
Chief Complaint: Fatigue
Vital Signs:
T: 99.7, P98, RR14, BP165/95 (repeat BP 170/100)
Learner Instructions (LI)
Learner Instructions:You have 30 minutes to:
1. Obtain a patient-centered, focused history appropriate for the patient's chief complaint and any other complaints uncovered.
2. Perform a focused physical exam appropriate for the history obtained.
3. Consider and address emotional and social needs of the patient and his support system.
4. Develop an initial care plan and communicate this plan to patient and/or patient's support system.
Remember: Talking with your preceptor or team is NOT an option.
You will then have 7 minutes to write a structured note at the computer outside your exam room door.
Return to that computer and begin your note. A timer will keep you informed of how much time is left.
***Students should use ALL of their time if possible, as those who finish significantly early often do not flesh out a more comprehensive DDX on the history and PE elements. If they DO finish early, once they leave the room, they CANNOT re-enter. However, they can then spend more time on their Note.
Honor Code (HC)- Please review this with your students -DO NOT DISCUSS CASES (testing continues over several weeks)
21.It is considered a violation of the honor code to discuss (either by giving or receiving information) cases, feedback, your performance, the logistics of the exam or anything related to this exam with others, either before, during or following the exam. Please initial in the box to the right that you agree to abide by the honor code for this case.
Please select "SUBMIT" at the bottom of this section before you enter the exam room. Please do NOT close the Learning Space software program.
SP EVALUATION- Students should focus on “5” column
SP SPA 1 (History) (SPA 1)
1.Item 4: Eliciting the Narrative Thread
Notes: / The Learner encouraged and let the patient talk about the patient's problem(s). The Learner did not stop the patient or introduce new information.
/ ()
5. The Learner encouraged and let the patient talk about the patient's problem(s). The Learner did not stop the patient or introduce new information. / ()
4 / ()
3. The Learner began to let the patient tell the patient’s story, but either interrupted with focused questions or introduced new information. / ()
2 / ()
1.
The Learner failed to let the patient tell the patient’s story.
OR
The Learner set the pace with a Q&A style, as opposed to a conversational style.
2.
Item 5: Timeline
Notes: / The Learner obtained sufficient information so that a chronology of the chief complaint and history of the present illness can be established. The chronology of any associated symptoms is also established.
/ ()
5. The Learner obtained sufficient information so that a chronology of the chief complaint and history of the present illness can be established. The chronology of any associated symptoms is also established. / ()
4 / ()
3. The Learner obtained some of the information necessary to establish a chronology.
The Learner failed to establish a chronology for any associated symptoms. / ()
2 / ()
1. The Learner failed to obtain information necessary to establish a chronology.
3.
Item 6: Questioning Skills--Types of Questions (edited)
Notes: / The Learner begins information gathering with more than one open-ended question. This is followed up by more specific or direct questions. No poor question types are used.
/ ()
5. The Learner begins information gathering with more than one open-ended question. This is followed up by more specific or direct questions. No poor question types are used. / ()
4 / ()
3. The Learner often failed to begin a line of inquiry with open-ended questions, but rather employed specific or direct questions to gather information.
OR
The Learner used a few leading, why, or multiple questions. / ()
2 / ()
1. The Learner asked many why questions, multiple questions, or leading questions.
4.
Item 21: Closure
Notes: / At the end of the interview the Learner clearly specifies the future plans as to What the Learner will do (make referrals, order tests), What the patient will do (make diet changes, go to physical therapy) and When (the time of the next communication or appointment).
/ ()
5. At the end of the interview the Learner clearly specifies the future plans as to What the Learner will do (make referrals, order tests), What the patient will do (make diet changes, go to physical therapy) and When (the time of the next communication or appointment). / ()
4 / ()
3. At the end of the interview, the Learner partially detailed the plans for the future. / ()
2 / ()
1. At the end of the interview, the Learner failed to specify the plans for the future and the patient left the interview without a sense of what to expect. There was no closure whatsoever.
5.
Comments:
SP SPA 2 (Physical Exam) (SPA 2)
6.Learner is cleansing hands when he/she enters the room or tells you they have cleaned their hands or washes hands at any point prior to the physical exam / ()
Yes / ()
No
7.
Examines you appropriately (not through gown or clothing). / ()
Yes / ()
No
8.
Drapes appropriately and protects modesty.
Notes: / Learner should lower gown from above to examine upper chest while keeping the breasts covered. The learner should raise the gown from below, keeping the breasts covered to examine the lower chest. For the abdominal exam the learner raises gown and lowers sheet to expose all of abdomen down to top of symphysis pubis. For straight leg raising places sheet between legs before doing straight leg raising.
/ ()
Yes / ()
No
9.
Learner describes physical exam or procedures to you
Notes: / Learner should tell patient that he/she is going to do a physical exam. Should explain in general terms each body system exam (I'm going to examine your heart now, I'm going to examine your abdomen now, etc.).
/ ()
Yes / ()
No
10.
Learner considers your comfort during exam
Notes: / Pulls out foot rest when patient is laying down; avoids unnecessary position changes, helps or offers to help patient sit/stand up, is not unnecessarily rough with physical exam.
/ ()
Yes / ()
No
11.
Comments:
SP SPA 7 (Communication) (SPA 7)
12.Item 1: Opening
Notes: / The Learner opened by introducing themselves (including their last name), clarifying their role, and greeting the patient. The greeting should include good eye contact and a smile.
/ ()
5. The Learner opened by introducing themselves (including their last name), clarifying their role, and greeting the patient. The greeting should include good eye contact and a smile. / ()
4 / ()
3. The Learner’s introduction is missing a critical element. / ()
2 / ()
1. There is no introduction.
13.
Item 8: Lack of Jargon
Notes: / The interviewer asks questions and provides information in language that is easily understood; content is free of difficult medical terms and jargon. Words are IMMEDIATELY DEFINED for the patient. Language is used that is appropriate to the patient's level of education.
/ ()
5. The interviewer asks questions and provides information in language that is easily understood; content is free of difficult medical terms and jargon. Words are IMMEDIATELY DEFINED for the patient. Language is used that is appropriate to the patient's level of education. / ()
4 / ()
3.The Learner occasionally used medical jargon during the interview and failed to define the medical terms for the patient unless specifically requested to do so by the patient. / ()
2 / ()
1. The Learner used difficult medical terms and jargon throughout the interview.
14.
Item 13: Verbal Facilitation Skills
Notes: / The Learner used facilitation skills throughout the interview. Verbal encouragement, use of short statements and echoing were used when appropriate.
/ ()
5. The Learner used facilitation skills throughout the interview. Verbal encouragement, use of short statements and echoing were used when appropriate. / ()
4 / ()
3. The Learner used some facilitative skills, but not consistently or at appropriate times. Verbal encouragement could have been used more effectively. / ()
2 / ()
1. The Learner failed to use facilitative skills to encourage the patient to tell his story.
15.
Item 14: Non-Verbal Facilitation Skills
Notes: / The Learner put the patient at ease and facilitated communication by using good eye contact; relaxed, open body language; and appropriate facial expressions; and by eliminating physical barriers. Physical contact was made with the patient, as appropriate.
/ ()
5. The Learner put the patient at ease and facilitated communication by using good eye contact; relaxed, open body language; and appropriate facial expressions; and by eliminating physical barriers. Physical contact was made with the patient, as appropriate. / ()
4 / ()
3. The Learner made some use of facilitative techniques, but could be more consistent in that one or two techniques were not used effectively. A physical barrier was present. / ()
2 / ()
1. The Learner made no attempt to put the patient at ease. The Learner’s body language was negative or closed. Annoying mannerisms (foot or pencil tapping) intruded on the interview. Eye contact was not attempted or was uncomfortable.
16.
Item 15 (edited): Empathy and Acknowledging Patient Cues
Notes: / The Learner used supportive comments regarding the patient’s emotions and provided the patient with intermittent verbal encouragement, such as verbally praising the patient for proper health care techniques.
NOTE: Patient cue in this case is to express concern about the seriousness of her symptoms. The learner is expected to acknowledge the patient's concerns.
/ ()
5. The Learner used supportive comments regarding the patient’s emotions and provided the patient with intermittent verbal encouragement, such as verbally praising the patient for proper health care techniques. / ()
4 / ()
3. A few empathetic statements were used and the Learner was neutral, neither overly positive nor negative in demonstrating empathy during the interview. Verbal encouragement could have been used more effectively. / ()
2 / ()
1. No empathy was demonstrated by the Learner. The Learner used a negative
emphasis or openly criticized the patient. The Learner provided no encouragement.
17.
Item 16: Encouragement of Questions
Notes: / The Learner encouraged the patient to ask questions about the topics discussed. The Learner also gives the patient the opportunity to bring up additional topics or points not covered in the interview (e.g., "We've discussed many things. Are there any questions you might like to ask concerning your problem?" Is there anything else at all you'd like to talk about?") This is particularly important at the end of the interview.
/ ()
5. The Learner encouraged the patient to ask questions about the topics discussed. The Learner also gives the patient the opportunity to bring up additional topics or points not covered in the interview (e.g., "We've discussed many things. Are there any questions you might like to ask concerning your problem?" Is there anything else at all you'd like to talk about?") This is particularly important at the end of the interview. / ()
4 / ()
3. The Learner provided the patient with the opportunity to discuss any additional points or ask any additional questions, but neither encouraged nor discouraged the patient. / ()
2 / ()
1. The Learner failed to provide the patient with the opportunity to ask questions or discuss additional points. The Learner may have discouraged questions from the
patient.
18.
Item 18 - Patient Education and Understanding
Notes: / The Learner used deliberate techniques to determine the patient’s understanding of the information given to the patient during the interview, including the diagnosis.
These techniques included asking the patient to repeat information, asking if the patient has any additional questions, posing hypothetical situations, or asking the patient to demonstrate techniques.
Where patient education was a goal, the Learner determined the patient’s level of education and interest and provided appropriate medical and technical information education accordingly.
/ ()
5. The Learner used deliberate techniques to determine the patient’s understanding of the information given to the patient during the interview, including the diagnosis.
These techniques included asking the patient to repeat information, asking if the patient has any additional questions, posing hypothetical situations, or asking the patient to demonstrate techniques. Where patient education was a goal, the Learner determined the patient’s level of education and interest and provided appropriate medical and technical information education accordingly. / ()
4 / ()
3. The Learner asked the patient if he understood the given information, but did not use a deliberate technique to check the patient’s understanding.
The Learner made some attempt to check the patient’s interest and understanding, but could have been more thorough. / ()
2 / ()
1. The Learner failed to assess the patient’s level of understanding and did not effectively correct misunderstandings when it was evident such a situation existed. AND/ORThe Learner completely failed to address the issue of patient education and understanding.
19.
Comments:
Patient Satisfaction (PS)
20.This was a satisfying visit for me. / ()
5. My concerns were addressed in a satisfactory manner. I liked this learner. I feel confident that he/she will address the things that are concerning me. This is a doctor I would be interested in seeing when he/she finishes training. / ()
4. / ()
3. There were some aspects of the visit that were satisfying and others that were not. / ()
2. / ()
1. My problems were dismissed or trivialized. The learner's assessment and/or plan did not make sense or were unacceptable. I did not have input into the plan. The learner was rude or unprofessional.
Faculty Observation and Narrative
FON SPA 1 (History) (Hx)- Full credit for “yes”
Note that this sample checklist applies to this specific case and is only appropriate for this specific presentation.With a different presentation a different checklist would likely be appropriate. It is presented only as an example and should not be interpreted as "the list" of history questions to ask for every case26.
CC: Establishes or confirms the chief complaint or reason for the visit? / () Yes
() No
27.
HPI: Other symptoms associated with the fatigue
Notes: / This may be a general questions or question(s) about specific symptoms such as those listed under ROS.
/ () Yes
() No
28.
HPI: Location or character of epigastric discomfort / () Yes
() No
29.
HPI: Aggravating factors: / () Yes
() No
30.
HPI: Alleviating factors: / () Yes
() No
31.
HPI:Timing
Notes: / Only 1 question required to score "yes" such as onset, constant or intermittent, getting worse since onset, etc.
/ () Yes
() No
32.
HPI: Severity
Notes: / For pain quantified on a 10 pt. scale. For other symptoms (CP, orthopnea/PND, shortness of breath, etc. better quantified by a description of how much it interferes with ADLs (activities of daily living).
/ () Yes
() No
33.
HPI: History of these sx before? / () Yes
() No
34.
HPI: Risk factors for coronary disease or CHF or cancer (HTN, DM, hyperlipidemia, smoking)
Notes: / Must specifically ask 2 of 3 to get a "yes"
/ () Yes
() No
35.
PMH: Past medical history
Notes: / chronic illnesses, hospitalizations, surgeries. Any 1 question is sufficient.
/ () Yes
() No
36.
PMH: Prescription Medications? / () Yes
() No
37.
PMH: OTC Medications?
Notes: / must ask specifically about OTC medications or say "do you take anything like vitamins, herbs, supplements, etc.
/ () Yes
() No
38.
PMH: Medication Allergies? / () Yes
() No
39.
FH: Specifically asks about family history of heart disease or family risk factors (DM, HTN, hyperlipidemia, etc.) (either question will get the student a "yes")
Notes: / Learner should NOT get credit for this item if the patient volunteers it with the "prompt" built into the case at the 5 min. warning. (If the FH of early death of father has not come up at the 5 min. warning the patient is to say "I'm really worried that I'm going to be like my father - he had a heart attack and died.")
/ () Yes
() No
40.
SH: Smoking Hx?
Notes: / If he/she has ever smoked need to find number of years and packs smoked per day. If prior smoker and has stopped need to find out how many years since he's smoked.
/ () Yes
() No
41.
SH: Recreational drug use?
Notes: / If yes, need to determine drug, quantity and frequency.
/ () Yes
() No
42. SH: Alcohol Hx?
Notes: / If yes, need to determine drug, quantity and frequency.
43.
ROS: Pulmonary: Dyspnea?
Notes: / Any question about shortness of breath or difficulty breathing with this episode or prior to this episode is sufficient
/ () Yes
() No
44.
ROS: CV: Palpitations? Orthopnea? PND?
Notes: / Any questions about rapid heart beat or unusual awareness of heart beat is sufficient
/ () Yes
() No
45.
ROS: GI: Melena? Hematemesis? Epigastric pain?
Notes: / Question should be related to symptoms since onset of pain
/ () Yes
() No
46.
ROS: General: Sweating or cold/clammy feelings
Notes: / Question should be related to symptoms since onset of fatigue
/ () Yes
() No
48.
Comments:We encourage faculty to write comments on what you especially did well or need work on
FON SPA 2 (Physical Examination) (PE)- Full credit for “correct”, ½ for “incorrect”
Note that this sample checklist applies to this specific case and is only appropriate for this specific presentation. With a different history a different physical exam checklist would likely be appropriate. It is presented only as an example and should not be interpreted as "the list" of physical examinations for every case49.
Examines heart and abdomen from the patient's right side
Notes: / Must be on the patient's right side for both to score "yes."
/ () Yes
() No
50.
Lungs: Auscultation anteriorly (upper chest in front) through full inspiration/expiration cycle at one location bilaterally.
Notes: / Patient must be asked to breathe in and out through mouth or take deep breaths. Stethoscope must remain in contact with the skin throughout a full cycle of inspiration & expiration.
/ () Correct Technique / () Incorrect Technique / () Not Done
51.
Lungs: Auscultates posteriorly (in the back) through full inspiration/expiration cycle at each of 3 locations bilaterally comparing left to right.
Notes: / Patient must be asked to breathe in and out through mouth or take deep breaths. Stethoscope must remain in contact with the skin throughout a full cycle of inspiration & expiration.
/ () Correct Technique / () Incorrect Technique / () Not Done
52.
Lungs: Auscultates right middle lobe laterally underneath right arm or under R breast.
Notes: / Patient must be asked to breathe in and out through mouth or take deep breaths. Stethoscope must remain in contact with the skin throughout a full cycle of inspiration & expiration to score "correct".
/ () Correct Technique / () Incorrect Technique / () Not Done
53.
CV: Assess Jugular Venous Pulsation
Notes: / Must raise the bed at least to a 30-degree angle (or at angle where you can see top of neck veins), have the patient turn his/her head to the side and inspect the jugular venous pulse for height and wave patterns. This exam can be done with the patient turning his/her head away from or towards the examiner. SINCE IT IS DIFFICULT TO JUDGE ANGLE OF ELEVATION ON VIDEO ANY ELEVATION OR ATTEMPT TO ELEVATE THE BED WILL COUNT AS ACCEPTABLE ELEVATION.
/ () Correct Technique / () Incorrect Technique / () Not Done
54.
CV: Palpates apical impulse
Notes: / Patient must be supine (laying down). In women the student or patient may need to displace breast. To do so the student should use the back of his/her hand or ask the patient to do so. Women may also need to hold up the underwire or elastic of the bra.
/ () Correct Technique / () Incorrect Technique / () Not Done
55.
CV: Auscultates heart with the diaphragm in the correct 4 listening areas with patient supine (laying down).
Notes: / right second intercostal space (aortic area)
over left second intercostal space (pulmonic area),
down the left sternal border (tricuspid)
over the apex (mitral)
/ () Correct Technique / () Incorrect Technique / () Not Done
56.
CV: Auscultates heart with the bell in the mitral and tricuspid area.
Notes: / down the left sternal border (tricuspid)
over the apex (mitral)
/ () Correct Technique / () Incorrect Technique / () Not Done
57.
CV: Palpates pulses in upper extremities bilaterally.
Notes: / Only has to palpate one pulse bilaterally (brachial or radial).
/ () Correct Technique / () Incorrect Technique / () Not Done
57.
CV: Palpates pulses in lower extremities bilaterally.
Notes: / One is sufficient: dorsalis pedis (top of foot), posterior tibial (behind the inner ankle bone), or popliteal (behind the knee).
/ () Correct Technique / () Incorrect Technique / () Not Done
58.
CV: Checks for pedal edema by pressing on the patient's shin. / () Correct Technique / () Incorrect Technique / () Not Done
59. HEENT: Check for conjunctival pallor (could also check thyroid) / () Correct Technique / () Incorrect Technique / () Not Done
60.
Abdomen: Palpation light and deep in all 4 quadrants with knees flexed.
Notes: / Must do light and deep palpation in all 4 quadrants for full credit. Can do light and deep at each location OR do light at 4 quadrants then deep at 4 quadrants.
/ () Correct Technique / () Incorrect Technique / () Not Done
61. Abdomen: Palpate or percuss for hepatomegaly and splenomegaly / () Correct Technique / () Incorrect Technique / () Not Done
62.
COMMENTS:
FON SPA 8 (Difficult Communication) (SPA 8)- Many cases will have a communication component to be addressed (interpersonal dynamic, patient request, etc)