Interprofessional Standardized Patient Exercise: Patient Case (Draft 6)

Interprofessional Standardized Patient Exercise: Case Summary

Patient Name: Elsie Smith

Presenting Problem:

Patient presents to establish careafter an Emergency Department visit for a fall. Her main complaintsare balance problems and right jaw pain.

Actual Diagnoses:

Diabetesmellitus type 2

Peripheral neuropathy

Hypertension

Hyperlipidemia

Chronic kidney disease

Osteoarthritis

Glaucoma

Anxiety

Xerostomia

Reversible pulpitis due to extensive caries under right mandibular molar bridge abutment crown.

Generalized moderate periodontitis, with localized severe periodontitis

Patient Demographics:

Age: 75 years old

Sex: Female

Race: Open

Height: average

Weight: Overweight or average

Overview of Case:

Elsie Smith is a75 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.

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PRESENTING SITUATION and INSTRUCTIONS TO THE STUDENT

Elsie Smith

Elsie 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 bedtime

Pulse: 72Glipizide 20 mg twice a day

Respiration: 14Lisinopril 10 mg daily

Blood pressure: 152/89 Hydrochlorothiazide 12.5 mg daily

O2 Saturation: 100% on room air Aspirin 81 mg daily

Lipitor 80 mg daily

Neurontin 900 mg three times daily

Betaxolol 1 drop daily right eye

Pilocarpine 4% 1 drop four times daily right eye

Vicodin 5/500 mg 1-2 tabs two times daily as needed for pain

Lorazepam 0.5 mg three times daily as needed for anxiety

Height: 5 feet 2 inches

Weight: 155 pounds

Labs/Studies: (from ED visit 2 weeks ago)

Cholesterol 285 mg/dl (high)Na+ 140mmol/L (normal)

K+ 4.0mmol/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 disease

Jaw x-ray: no fracture

You 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 are5 minutes remainingand 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 yourinsulin 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 readingsin your handbag, which is next to you on the table. You sit with a slightly hunched posture.

History of Present Illness

Opening 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 fallingagain; 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 months

Questions related to your last fall

Tell 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 landedon 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 General

Have 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 whenI 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 balance

Why 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?Mylegsdon’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 falling

Do 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 pain

Tell 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 Vicodinare 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-raysand told me I have bad arthritis in my knee but nothing broken.

Questions related to right jaw pain

When 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 abouta 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

Diabetes

You 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 - 64

Tues -- (no caregiver)

Wed – 200

Thurs -- (no caregiver)

Fri - 242

Sat -- (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 pressure

This 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 cholesterol

This 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.

Arthritis

You know that you have had arthritis in both knees for a long time. Tylenoleffectively 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.