Lynn JenkinsSP Guide
Lynn Jenkins
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.
Standardized Patient’s Instructions:
Your facilitator will let you know how he/shewill be using you during the session(s). For example, your facilitator may choose to ask you to enter the room only when the students are instructed to interview the patient. He/she may ask you to leave the room and sit on a chair by the door for the remainder of the case. Your facilitator may also choose to keep you in the room through the entire session, only asking you to speak during the SP activities. In addition, you will be encouraged to provide direct feedback to the students at the end of each session. The bottom line is you will play the role of the patient as instructed by your facilitator.
Scenario:
The student is starting aclinical rotation at a family practice center. The first day was just observation, but today Dr. Weston asks the student to see you, Lynn Jenkins, whom Dr. Weston has seen once before. The doctor asks the student to obtain a complete history, because he didn’t have the time to do it at the last visit.
SP NOTES
Lynn Jenkins is a 34 year old female
SIMULATED PATIENT– You shouldlook 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 or7.”
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 hypertensionon 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 3rdof 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, shefeels guilty about drinking with her kids around, she has never hadan 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 andpresentations. Feels guilty she cannot work now felt guilty about being at work when kids were home (eg. school holidays)
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.
Scenario:
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 laterthough, 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.
A student will take a history from you. Script below.
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.
A student will talk to you about the treatment plan. Script below.
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.
A student will give you advice. Script below.
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.”
END OF CASE
1
[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.