facilitator’s manual - aamc … · fellowship osce facilitator’s manual. miami, florida:...

of 193

FACILITATOR’S MANUAL

Title: Geriatric Medicine Fellowship OSCE

Prepared by: Anita Bagri, MD and Jorge Ruiz, MD

Faculty Contributors: Enrique Aguilar, MD Paul Cherniack, MD Adam Golden, MD Regina Marranzini, MD Marcos Milanez, MD Juan Carlos Palacios, MD Osvaldo Rodriguez, MD Renuka Tunuguntla, MD Khin Zaw, MD

Acknowledgments: Andrea Ruiz, Fellowship Coordinator 2007-2008 Fellows: Heather Capello, MD Carlos Fontanez, MD Mayra Cruz, MD Fellipe Oliveira, MD Maria De Pool, MD Alex Sanchez, MD Hector Fabregas, MD Christian Seda, MD

Date of last revision: March 20, 2009

of 193

Index

Description ................................................................................................... 4

Purpose and Educational Goals................................................................... 4

Intended Audience ....................................................................................... 4

General Structure......................................................................................... 4

Prerequisites ................................................................................................ 5

Instructor Qualifications and Responsibilities............................................... 5

Required Resources .................................................................................... 5

Procedures for Implementation .................................................................... 5

Assessment.................................................................................................. 7

Feedback and Remediation ......................................................................... 7

Evaluation .................................................................................................... 7

Extension Activities ...................................................................................... 7

Lessons Learned.......................................................................................... 8

Citation......................................................................................................... 8

References................................................................................................... 8 Station 1: Interdisciplinary Team Meeting ..................................................................12

Checklist: IDT Meeting.......................................................................................................................14 Station 1: Example case....................................................................................................................16 Station 1: Helpful guidelines for scoring ............................................................................................23

Station 2: Performance-Oriented Mobility Assessment..............................................24 Checklist: POMA................................................................................................................................26 Station 2: POMA Scoring Form .........................................................................................................28

Station 3: Counseling about Preventive Care ............................................................30 Checklist: Preventive Care ................................................................................................................32 Station 3: Standardized Patient Script...............................................................................................34

Station 4A: Telephone Medicine ................................................................................35 Checklist: Telephone .........................................................................................................................37 Station 4A: Standardized Patient Script ............................................................................................39

Station 4B: Telephone Medicine ................................................................................42 Checklist: Telephone .........................................................................................................................44 Station 4B: Standardized Patient Script ............................................................................................46

Station 5: Withholding & Withdrawal of Treatment.....................................................50 Checklist: Withholding & Withdrawal of Treatment ...........................................................................52 Station 5: Standardized Patient Script...............................................................................................54

Station 6: Delivering Bad News..................................................................................57 Checklist: Delivering Bad News.........................................................................................................59 Station 6: Standardized Patient Script...............................................................................................61

Station 7: Discussing Do Not Resuscitate (DNR).......................................................65 Checklist: Discussing DNR................................................................................................................67 Station 7: Standardized Patient Script...............................................................................................69

Station 8: Assessing Decision Making Capacity ........................................................70 Checklist: Decision Making Capacity.................................................................................................72 Station 8: Standardized Patient Script...............................................................................................74

Geriatric Medicine Fellowship OSCE 2007-2008

of 193

Station 8: Helpful guidelines for scoring ............................................................................................76 Station 9: Elder Abuse ...............................................................................................77

Checklist: Elder Abuse.......................................................................................................................79 Station 9: Standardized Patient Script...............................................................................................81 Station 9: Standardized Caregiver Script ..........................................................................................86

Station 10: Cognitive Impairment ...............................................................................94 Checklist: Cognitive Impairment ........................................................................................................96 Station 10: Standardized Patient Script.............................................................................................98 Station 10: Standardized Caregiver Script ......................................................................................103

Station 11: Falls .......................................................................................................110 Checklist: Falls.................................................................................................................................114

Station 12: Rehabilitation Potential ..........................................................................117 Checklist: Rehabilitation Potential ...................................................................................................122

Station 13: Placement Decisions .............................................................................125 Checklist: Placement .......................................................................................................................129

Station 14: Delirium..................................................................................................132 Checklist: Delirium...........................................................................................................................137

Station 15: Chronic Pain ..........................................................................................140 Checklist: Chronic Pain....................................................................................................................144

Station 16: Depression.............................................................................................147 Checklist: Depression......................................................................................................................151

Station 17: Dizziness ...............................................................................................154 Checklist: Dizziness.........................................................................................................................158

Station 18: Malnutrition ............................................................................................161 Checklist: Malnutrition......................................................................................................................165

Station 19: Pressure Ulcers .....................................................................................168 Checklist: Pressure Ulcers...............................................................................................................172

Station 20: Insomnia ................................................................................................175 Checklist: Insomnia..........................................................................................................................179

Station 21: Urinary Incontinence ..............................................................................182 Checklist: Urinary Incontinence .......................................................................................................186

Station 22: Polypharmacy ........................................................................................189 Checklist: Polypharmacy .................................................................................................................192

of 193

Description We designed a 22-station OSCE for geriatric medicine fellows to assess competency in common geriatric assessment tools and interactions, interpersonal and communication skills, and clinical reasoning in common geriatric syndromes.

Purpose and Educational Goals The OSCE aims to reinforce skills that are necessary and relevant to the practice of geriatric medicine. Intended for use as a formative assessment tool, we administered the OSCE five months into the one year clinical fellowship. This provided fellows with ample time to identify personal weaknesses, receive targeted feedback, review suggested educational materials, and improve upon their knowledge and/or skills before completion of the fellowship.

Intended Audience The OSCE is intended for first year, clinical geriatric medicine fellows.

General Structure Real Clinical Scenarios 1 Conduct an Interdisciplinary Team (IDT) meeting 2 Complete the Performance Oriented Mobility Assessment (POMA) Standardized Patient Stations 3 Preventive care in the elderly 4 Telephone medicine 5 Withholding and withdrawal of care 6 Delivering bad news 7 Discussing a Do-Not-Resuscitate (DNR) order 8 Assessing decision making capacity 9 Elder abuse 10 Cognitive impairment Case-based Computerized Vignettes 11 Falls 12 Rehabilitation potential 13 Placement decisions 14 Delirium 15 Chronic pain management 16 Depression 17 Dizziness 18 Malnutrition 19 Pressure ulcers 20 Urinary incontinence 21 Insomnia 22 Polypharmacy


of 193

Prerequisites A list of competencies to be assessed in the OSCE is distributed to all fellows prior to the examination to guide preparatory efforts. All fellows complete a sample computer-based online case before the examination to familiarize themselves with the computer program.

Instructor Qualifications and Responsibilities Geriatric medicine attending physicians and/or senior fellows should be responsible for training standardized patients, scoring each station, providing feedback, and facilitating remediation sessions (see below).

Required Resources Eight rooms with videotaping capabilities (i.e. clinical skills laboratory, simulation center) are required. An overhead intercom system is preferred but not mandatory. The fellows conduct a physical examination in only two stations, so those rooms should have a sink or alcohol hand gel dispenser, gowns, and an examining table. Please refer to the appendices for these stations for a full list of specific props required. For the remaining stations, a room set up with two chairs will suffice. We used the software package Nero (Nero, Inc.) to transfer videos from VHS to DVD for distribution to fellows and scoring attendings.

Procedures for Implementation Real clinical scenarios Stations 1-2 1.

Station 1: IDT meeting This activity requires that two attendings observe a fellow conducting an IDT meeting where at a minimum the following disciplines are in attendance: social work, physical therapy, nutrition, pharmacy, and nursing. Interpersonal skills aimed at balancing group dynamics and maximizing efficiency are the goals of this station. Immediate feedback is provided. Station 2: POMA administration In the outpatient setting, two attendings observe the fellow administering a POMA to a real patient. Proper instruction, guarding techniques, and accurate scoring are the main goals of this station. Immediate feedback is provided.


of 193

Standardized patient stations Stations 3-10 2.

All fellows complete all standardized patient stations in one morning session. Faculty and staff, trained by attendings in the Division, act as standardized patients. A total of ten standardized patients will be needed. Fellows are allotted fifteen minutes to complete each station, and there is a five minute break between stations. At the beginning of each station, fellows read the clinical scenario and specific instructions on the skill they are to perform. They are notified when they have five minutes left in each station either via overhead intercom or a knock on the door. Audio and/or videotapes of each fellow’s performance are obtained for scoring and subsequent review. For Station 8 (Decision making capacity), Station 9 (Elder Abuse), and Station 10 (Cognitive impairment), written documentation of the fellow’s assessment and plan is required. The remaining stations do not require documentation of the clinical encounter and are scored solely on the basis of audio/videotape review.

Case-based computer vignettes Stations 11-22 3.

All fellows complete all computer-based stations in one afternoon session. The same patient management plan (PMP) template, based on Peabody’s clinical vignettes,1 is used for each computer-based station. One clinical scenario is provided, and at each step of history taking, physical exam, and laboratory/imaging work-up, the fellows are prompted to type what they would like to ask, examine, or order and to provide justification for their responses. Subsequent screens provide more information, but the cumulative patient data is not presented. That is, on the screen which asks them which diagnostic tests they would like to order, the patient’s initial history is not available for review. We chose this organization due to space constraints. Backtracking between screens is not allowed. The final task requires the fellows to communicate their assessment and plan. Twenty minutes are allotted for each station. The only exception to this format is Station 22 (Polypharmacy), where the fellows are asked simply to write their assessment and plan. For those without access to an online Learning Management System, all of these stations could be done via a paper-based format with no backtracking.


of 193

Assessment Using a standardized checklist of objectives and possible responses for each station, two attendings independently assign a pass or fail score. This is usually based on an overall assessment rather than the percentage of checklist items that are completed. For example, the fellow may neglect to perform the Dix-Hallpike maneuver on the patient with dizziness, and although most other elements are there, he may fail that station since that is a necessary step in the diagnosis of benign positional vertigo. For Stations 1 and 2, assessment and feedback are immediate. For the remaining 20 stations, audio/video tapes and written documentation are reviewed for scoring purposes. Any discrepancies between scores are resolved via discussion with a third party. Each fellow scores his/her performance at all stations using the same checklist of objectives. This self-assessment exercise does not affect the attending pass or fail score.

Feedback and Remediation All fellows receive individual formative feedback from one attending. Remediation for failed standardized patient stations takes place individually, and the fellow is requested to perform the task again. Small group remediation sessions occur for failed computer vignette stations, and the same case presented during the OSCE is reviewed and discussed as a group. Attendings or senior fellows facilitate all remediation sessions.

Evaluation Immediately following the OSCE, fellows complete a questionnaire of Likert-scale items and open-ended questions about the experience and the value of participating in the OSCE. (see Appendix entitled “Questionnaire”)

Extension Activities For each failed station, we provided the fellows with educational materials to review prior to the remediation sessions. These included review articles, DVDs, and online interactive modules. (see Appendix entitled “Remediation Resources”)


of 193

Lessons Learned We have implemented the Geriatric Medicine Fellowship OSCE for the past two years. After the first year, we conducted semi-structured individual interviews to explore each fellow’s attitudes and perceptions about the OSCE experience.

• Given that all of our fellows had experience with standardized patients in the past, this portion was the most well-received and in-line with their expectations.

• Regarding the computer-based vignettes, however, fellows reported great frustration, citing insufficient time and unclear instructions as the main reasons. We modified the format for the next year, utilizing the PMP template, which resulted in more favorable reactions.

• Prior to the OSCE, fellows have access to a sample computer PMP. They requested feedback after completing the case or access to the correct responses to see if they are appropriately answering the questions.

• Fellows endorsed varying degrees of anxiety and mixed feelings regarding the use of familiar faculty and staff as standardized patients.

• Discordance between attending and fellow self scoring was common, and many were concerned that the exam did not accurately measure real-world competence. These doubts of exam validity were a surprising finding, and they may relate to the acceptability and authenticity of the exam.

• Fellows believed the OSCE was worthwhile and in particular identified the feedback and remediation sessions as the most useful parts of the experience.

Citation Bagri AS, Ruiz JG, Aguilar EJ, Cherniack EP, Golden A, Marranzini NR, Milanez MN, Palacios JC, Rodriguez O, Tunuguntla R, Zaw KM. Geriatric Medicine Fellowship OSCE Facilitator’s Manual. Miami, Florida: Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Healthcare System and the University of Miami Miller School of Medicine, 2008.

References 1. Peabody JW, Luck J, Glassman P, et al. Measuring the quality of physician practice by using clinical vignettes: a prospective validation study. Ann Intern Med 2004;141:771–780.

of 193

Appendix: Questionnaire

Statement Likert-scale response (5=strongly agree, 4=agree, 3=neutral, 2=disagree, 1=strongly disagree)

1 Overall, the OSCE was a worthwhile exercise. 5 4 3 2 1 2 The faculty feedback has been helpful. 5 4 3 2 1 3 I am generally anxious before an exam. 5 4 3 2 1 4 It is unnecessary to assess the clinical skills of geriatric

medicine fellows. 5 4 3 2 1

Explain: 5 Clinical assessment may be useful for geriatric medicine

fellows, but there are better methods available. 5 4 3 2 1

Explain: 6 I felt poorly prepared for the OSCE. 5 4 3 2 1 7 The OSCE exam was anxiety provoking. 5 4 3 2 1 8 I have had one-on-one feedback before. 5 4 3 2 1 9 The OSCE was a fair assessment. 5 4 3 2 1 Explain: 10 The OSCE exam was structured in a well organized manner. 5 4 3 2 1 11 The standardized patients were realistic. 5 4 3 2 1 12 I was clear about the goals of the OSCE. 5 4 3 2 1 Explain: 13 I learned a great deal from the OSCE. 5 4 3 2 1 14 The OSCE had a good balance of cases. 5 4 3 2 1 Explain: 15 If given an opportunity, I would like to do the OSCE again. 5 4 3 2 1 Explain: 16 I will incorporate what I have learned today into my clinical

practice/teaching practice. 5 4 3 2 1

17 The content of the stations was relevant to geriatric practice. 5 4 3 2 1 18 I had enough time to complete the standardized patient

stations. 5 4 3 2 1

19 I had enough time to complete the computer-based patient management problem stations.

5 4 3 2 1

20 What was your favorite station and why?

21 What was your least favorite station and why?

22 What did you anticipate the OSCE would be like?

23 What changes would you suggest we implement in the future?

24 Do you have any other comments?

of 193

Appendix: Remediation Resources

Station Educational Resources for Remediation

2 Ruiz JG et al. Interactive Performance Oriented Mobility Assessment (iPOMA). MedEdPortal; 2006. Available from http://www/aamc.ord/mededportal. ID = 241.

3 Takahashi PY et al. Preventive health care in the elderly population: a guide for practicing physicians. Mayo Clin Proc 2004 Mar;79(3):416-27.

4 1. Katz HP et al. Patient safety and telephone medicine: some lessons from closed claim case review. J Gen Intern Med 2008 May;23(5):517-22.

2. Boockvar KS, Lachs MS. Predictive value of nonspecific symptoms for acute illness in nursing home residents. J Am Geriatr Soc 2003 Aug;51(8):1111-5.

3. Elnicki DM et al. Telephone medicine for internists. J Gen Intern Med 2000 May;15(5):337-43.

5 Zeman A. Persistent vegetative state. Lancet 1997 Sep 13;350(9080):795-9. 6 1. Buckman R et al. 4 CD-ROMs. Practical Guide to Communication Skills in Clinical

Practice. Toronto Sunny Brook Regional Cancer Center, University of Southern California School of Medicine, and M.D. Anderson Cancer Center. Medical Audio Visual Communications, 1998.

2. McCann R, Chodosh J. End of Life Discussions – An Educational DVD. The University of Rochester School of Medicine and Dentistry.

3. Speak the Truth – An Educational Interactive DVD to Teach Giving Bad News. The University of Texas Medical Branch at Galveston.

7 van Gunten C. Discussing Do-Not-Resuscitate Status. Journal of Clinical Oncology 2001 Mar;19(5):1576-81.

8 Grisso T, Appelbaum PA. The Assessment of Decision-Making Capacity: A Guide for Physicians and Other Health Professionals. Oxford: Oxford University Press, 1998.

9 Lachs MS, Pillemer K. Elder Abuse. The Lancet 2004;364:1263-72. 10 1. Holsinger T et al. Does this patient have dementia? JAMA 2007 Jun;297(21):2391-

404. 2. G. Waldemara et al. Recommendations for the diagnosis and management of

Alzheimer’s disease and other disorders associated with dementia: EFNS guideline. European Journal of Neurology 2007, 14: e1–e26. doi:10.1111/j.1468-1331.2006.01605.x.

11 Tinetti ME. Preventing falls in elderly persons. N Engl J Med 2003 Jan;348(1):42-9. 12 1. Cruise CM et al. Rehabilitation outcomes in the older adult. Clin Geriatr Med 2006

May;22(2):257-67. 2. Cristian A. The assessment of the older adult with a physical disability: a guide for

clinicians. Clin Geriatr Med. 2006 May;22(2):221-38. 3. Mosqueda LA. Assessment of rehabilitation potential. Clin Geriatr Med 1993

Nov;9(4):689-703. 13 1. Gaugler JE et al. Predicting nursing home admission in the U.S: a meta-analysis. BMC

Geriatrics 2007 Jun;7(13). doi:10.1186/1471-2318-7-13. 2. Zimmerman S et al. Assisted Living and Nursing Homes: Apples and Oranges? The

Gerontologist 2003;43(Special Issue II):107–17. 3. Kissam S et al. Admission and Continued-Stay Criteria for Assisted Living Facilities. J

Am Geriatr Soc 2003 Nov;51(11):1651–54. 14 1. Inouye SK. Delirium in older persons. N Engl J Med 2006 Mar;354(11):1157-65.

2. Milisen K et al. Multicomponent intervention strategies for managing delirium in hospitalized older people: systematic review. J Adv Nurs 2005 Oct;52(1):79-90.


of 193

15 Abrahm JL. Management of pain and spinal cord compression in patients with advanced cancer. ACP-ASIM End-of-life Care Consensus Panel. American College of Physicians-American Society of Internal Medicine. Ann Intern Med 1999 Jul;131(1):37-46.

16 Unützer J. Late-Life Depression. N Engl J Med 2007 Nov;357(22):2269-76. 17 1. Eaton DA, Roland PS. Dizziness in the older adult, Part 1. Evaluation and general

treatment strategies. Geriatrics 2003 Apr;58(4):28-30,33-6. 2. Eaton DA, Roland PS. Dizziness in the older adult, Part 2. Treatments for causes of

the four most common symptoms. Geriatrics 2003 Apr;58(4):46,49-52. 18 Ritchie CS, McClave SA. Part II. Common nutritional issues in older adults. Dis Mon 2002

Nov;48(11):713-24. 19 Bates-Jensen BM, MacLean CH. Quality indicators for the care of pressure ulcers in

vulnerable elders. J Am Geriatr Soc 2007 Oct;55 Suppl 2:S409-16. 20 McCall WV. Sleep in the Elderly: Burden, Diagnosis, and Treatment. Prim Care

Companion. J Clin Psychiatry 2004;6(1):9-20. 21 Ruiz JG et al. Urinary Incontinence and Overactive Bladder in Older Adults Program.

Web-based modules. GeriU The Online Geriatrics University, Stein Gerontological Institute; 2007. Available from http://www.geriu.org.

22 1. Gurwitz JH. Polypharmacy: a new paradigm for quality drug therapy in the elderly? Arch Intern Med 2004 Oct;164(18):1957-9.

2. Hajjar ER et al. Polypharmacy in elderly patients. Am J Geriatr Pharmacother 2007 Dec;5(4):345-51.

3. Fick DM et al. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med 2003 Dec;163(22):2716-24.

of 193

Station 1: Interdisciplinary Team Meeting Issue Conducting an interdisciplinary team meeting Presenting Situation A complete interdisciplinary team meeting in either the nursing home or Geriatric Evaluation and Management (GEM)/Hospice unit Activity Participation in interdisciplinary team meeting Time Required 60 minutes This station was developed by Marcos Milanez, MD


of 193

Station Number 1 You will be observed by two geriatrics attendings while you conduct an interdisciplinary team meeting in the nursing home or GEM unit during your block rotation in that area.


of 193

Geriatric Medicine Fellowship OSCE

Checklist: IDT Meeting Station 1

Date: Fellow: Location:

Yes No

1. Communicated the patient’s medical illnesses in a professional way while making it relevant to other team members

2. Set priorities, in order of impact, on the older adult patient who frequently has multiple symptoms, diseases, and disabilities

3. Demonstrated leadership as appropriate

4. Solicited and incorporated in treatment planning other team members’ input, with awareness of differences in their roles and expertise

5. Recognized/appreciated models of geriatric care in interdisciplinary teams

6. Demonstrated appropriate interpersonal skills and respect when dealing with other team members

7. Solicited and incorporated in treatment planning patient/family wishes and values with awareness of different cultural health beliefs and practices

8. Listened attentively to others during interactions/conversations especially regarding patients

9. Proposed rational discharge planning

10. Explained rationale of his/her plan/actions to other team members Comments or Clarifications:


of 193

1. How would you rate the candidate's participation in interdisciplinary team meeting?

Excellent

Good

Fair

Inadequate

Poor

2 How would you rate the candidate's ability to address the geriatric issues during the interdisciplinary team meeting?

Excellent

Good

Fair

Inadequate

Poor

Station 1 Assessment Pass Fail

Assessor’s signature


of 193

Station 1: Example case Chief Complaint: “My mother has not eaten well for the past two days.” Source: son, who is her caregiver History of present illness: Ms. Courtney is a 74 year-old woman with a past medical history significant for a stroke four years ago with mild residual dysarthria and dysphagia that requires pureed diet. Two days ago, her son noticed she was eating less and that she was sleeping during the day, which is unusual for her. Her son also observed that she had two episodes of incontinence yesterday. Ms. Courtney states that she feels tired but denies any other symptoms. She acknowledges that her appetite is decreased but denies pain, nausea, or vomiting. Past Medical History: 1. Cerebrovascular accident 4 years ago with mild residual dysarthria and dysphagia 2. Hypertension for 15 years, well controlled since the stroke 3. Hyperlipidemia 4. Obesity, but she has lost some weight since the stroke 5. Chronic leg edema, which the patient’s son attributes to a medication 6. Osteoarthritis of the knees, worse on the right for which she occasionally requires a cane to ambulate Past Surgical History: 1. Cholecystectomy about 35 years ago 2. Hysterectomy about 35 years ago Medications: 1. amlodipine 10 mg oral daily 2. hydrochlorothiazide 12.5 mg oral daily 3. lisinopril 20 mg oral daily 4. aspirin 81 mg oral daily 5. simvastatin 40 mg oral daily Over the counter medications: 1. acetaminophen 500 mg oral as needed for pain 2. chondroitin sulfate 500 mg oral twice a day 3. calcium and vitamin D one tablet oral three times a day She denies sharing pills, but the son states that her sister has given her sleeping pills on a couple of occasions. Allergies: The patient has no known allergies.


of 193

Social History: She lives alone in a two-bedroom condo which she owns. Her informal support system includes her son and her younger sister as well as several neighbors who occasionally come by to visit her. Her son sleeps at her home most nights, but he often spends weekends in his country home. Her sister lives in another condo in the same building. The sisters call each other several times a day. It is kept clean by a hired housekeeper. The patient attends a Baptist church. She has a living will designating her son as durable power of attorney and stating that no artificial prolongation of her life should be attempted if she had a terminal illness. The patient’s Medicare and private insurance cover all of her medical expenses. She also has long-term care insurance, as well as a retirement pension. Her son helps with some of her household costs. She completed an Associate in Arts degree from community college and retired from her job as a bank clerk when she turned 64 years old. Her husband died 15 years ago of lung cancer, after 35 years of marriage. They had only one son. Habits: The patient never smoked but was exposed to her husband smoking for 35 years. She never used alcohol or illicit drugs. Family History: Her sister has osteoarthritis and diabetes mellitus. Their parents died in an accident when they were young. Health Maintenance and Prevention: Last mammogram six months ago was normal Colonoscopy twelve years ago showed only a few diverticuli No Pap smear since her hysterectomy Immunizations are up to date, including influenza and pneumococcus Geriatric Review of Systems: General: Sleepiness and decreased appetite as above Special senses: Reduced visual acuity, corrected by reading glasses. No hearing deficits. Mouth and Teeth: no problems Respiratory: occasional dry cough, but no shortness of breath or hemoptysis Cardiovascular: no problems. Edema has been considered unimportant by the patient’s primary care physician. Gastrointestinal: no problems Genitourinary: recent episodes of incontinence as mentioned above. Usually the patient has no urgency or frequency. No dysuria at this time. Musculoskeletal: knee pain is mild and does not prevent ambulation. However, the patient admits that she rarely walks outside her home. Psychiatry: The son reports that the patient is forgetful and does not have energy for anything, but the patient denies and states that she is normally fine. Neurological: denies any focal weakness


of 193

Physical Exam: Temperature 100.6 F Height 66 in Weight 93.7 lb BP supine 98/36 sitting 86/34 HR supine 94 sitting 118 Respiratory rate 20 Pain 1/10 General : ambulates slowly into the office with a cane, in no acute distress

but demonstrates mild tachypnea HEENT : PERRL, EOMI, dry oral mucosa Neck : supple, no elevated JVP Chest : crackles at the right base Heart : RRR, normal S1S2, no m, g, or r Abdomen : soft, +BS, NT/ND, no masses Extremities : +2 peripheral pulses, 2+ bilateral ankle edema, normal ROM Skin : normal skin turgor, no skin breakdown Neuro : no gross sensory or motor deficits except for dysarthria and slight

intention hand tremors (non pill rolling), no cogwheel rigidity Mental Status: Alert and oriented to person and place, but not to time. Able to

follow simple commands but easily distracted. Thought processes organized, but the patient takes a long time to answer questions. Patient fell asleep twice during the interview.

Laboratory tests: WBC 16.50 H Neutrophils 84% Hemoglobin 9.0 L Hematocrit 26.50 L MCV 104 H Platelets 403 H Sodium 128.00 L Potassium 4.80 Chloride 99.00 Bicarbonate 23.00 BUN 19.00 Creatinine 0.80 Glucose 114.00 H Anion gap 11 UA: yellow, clear; specific gravity 1.027 (normal 1.01-1.03), pH 6.50 (normal 5-7) protein 10 mg/dL, negative for glucose, ketones, bilirubin, blood, nitrite, urobilinogen, leukocyte esterase Chest X-ray: Right lower lobe consolidation


of 193

Geriatric Assessment Tools: ADL and IADL inventories: At baseline, she is independent for ADLs. Two days ago, she became incontinent and required some help bathing and getting dressed. She still makes it to the bathroom for bowel movements but is having difficulty even to rise from the chair without assistance. For the past four years, her son has taken over some of her IADLs, such as managing finances and medications. She was still able to use the telephone and cook until a few days ago, but she often forgets to prepare meals timely. She has not taken public transportation since she retired. Her son drives her to the grocery store, where she can still buy food without help. MMSE: Her score today was 14/30, substantially lower that the last one obtained by her primary care physician three months ago (22/30). She missed points in orientation to time, attention and calculation, recall, writing, three-step command and drawing. Confusion Assessment Method: Positive due to acute change with inattention and change in level of consciousness. Geriatric Depression Scale: 1/15. The patient answered “yes” to “Do you prefer to stay home at night, rather than go out and do new things?” Performance Oriented Mobility Assessment: 8/35, used cane Balance 5/26

Unable to stand on either leg unsupported Unable to stand in semitandem or tandem position Unable to do toe/heel stand

Gait 3/9 Slow to initiate gait Mild staggering with turning

Could not step over objects in path Assessment and Plan: Medical: 1. Delirium is most likely due to pneumonia and hyponatremia. The patient will be admitted to the hospital and started on IV fluids as well as IV antibiotics. Medications that can worsen delirium (e.g., anticholinergic medications) will be avoided. Patient needs frequent orientation and encouragement to leave bed safely with assistance. Son will be asked to bring the patient’s glasses to maximize her sensory input. Upon discharge, the patient will need follow-up cognitive assessment until complete resolution of symptoms. 2. Community-acquired pneumonia: IV ceftriaxone and azithromycin, supplemental oxygen to maintain saturation above 92%. Patient is relatively hypotensive, most likely because of volume depletion but is also at risk for sepsis. Blood cultures will be obtained.


of 193

3. Hyponatremia: likely due to thiazide use and worsened by acute illness. Avoid hypotonic fluids. If diuretics needed, furosemide will be used instead of thiazides. Adverse drug reaction will be documented in chart, so that thiazides are not employed again in the future. 4. Urinary incontinence: acute, related to delirium. The patient will be prompted to urinate several times a day, so that excessive moisture in diaper area (with consequent risk of pressure ulcers) is avoided. Functional incontinence may disappear if the underlying cause (delirium) is eliminated. 5. History of hypertension and stroke: the patient currently has low blood pressure and orthostasis. Hydrochlorothiazide and amlodipine will be discontinued. Lisinopril will be held until blood pressure increases. Continue aspirin. 6. Dysphagia: because of the patient’s chronic difficulty with swallowing and her acutely worsened mental status, she will be assessed by speech therapy. Pureed diet and personal assistance with feeding will be ordered. Small, frequent meals will be given during the moments the patient is more alert. 7. Nutrition: Since the patient’s oral intake is currently decreased due to delirium and dysphagia, we will discuss with her son the option of inserting a temporary nasogastric tube versus closely monitoring and offering her supervised meals by mouth. As she is expected to recover, a permanent feeding tube will not necessary, but the son will be approached about the patient’s preferences regarding artificial feeding. Order albumin and prealbumin. Nutritionist will be consulted in order to choose best supplements. Weight will be monitored at least weekly. 8. Macrocytic anemia: may be due to B12 or folate deficiency. Alternatively, hypothyroidism, alcohol abuse and liver disease could be the cause. Folate and B12 levels, TSH and liver function tests will be ordered. 9. Chronic leg edema: likely an adverse effect of calcium-channel blocker. No signs of CHF or DVT. Edema will be monitored, as resolution is expected after calcium-channel blocker is discontinued. Functional: 1. Recent decline in function is due to delirium and pneumonia. She is at a high risk of falls as detected by abnormal POMA, but the patient has good rehabilitation potential. Physical and occupational therapy will be started in order to prevent further decline and facilitate recovery. Although her delirium may preclude participation in rehab, this is expected to improve with treatment of the underlying cause. A two-wheeled walker will be used until gait and balance are back to baseline. The physical therapist will then assess whether an assistive device will still be needed. Since previously the patient used a cane when her osteoarthritis symptoms got worse, it may be that her gait problems are not entirely due to acute illness.


of 193

2. The patient is expected to be discharged back to her home, so home health care with physical therapy will be ordered as soon as her pneumonia has been sufficiently treated in the hospital. An environmental assessment of the home will be requested, with special emphasis on extrinsic risk factors for falls. 3. The difficulty with managing finances and medications is possibly related to cognitive deficits caused by the CVA or by early Alzheimer’s pathology. Visual impairment is another possible contributing factor. The patient will receive an appointment for an eye exam upon discharge. Psychological: 1. The patient is currently experiencing hypoactive delirium due to acute medical illness. She meets criteria for delirium because of the acute and fluctuating change in level of consciousness, accompanied by decreased attention. In this case, there is no thought disorganization so far. Therefore, at this point anti-psychotics such as haloperidol are not indicated. Because delirium decreases her safety awareness, family members will be asked to be with the patient most of the time. In case no family member can stay, a sitter will be ordered and instructed to encourage the patient to ambulate within safe limits. 2. Although her current MMSE cannot be used as evidence of dementia, her MMSE in the primary care physician’s office three months before admission already revealed a low score for someone with college education. Moreover, the patient was already experiencing difficulty with managing finances and medications and often forgets to prepare meals timely. Her pre-existent cognitive impairment is one of her risk factors for delirium, even if it did not necessarily meet criteria for dementia. In any case, she needs to be monitored for resolution of symptoms and is at risk of further decline in the future. 3. Decision–making capacity is currently compromised by delirium. It is possible that she will not recover completely, although most of the recent decline should be transitory. Since recovery from delirium can be slow in the elderly, it will be important to reassess her capacity often. 4. This patient’s mood seems to be appropriate so far, but she is at risk of decline due to her chronic and acute problems. Periodic screening for depression is recommended during hospitalization (especially if prolonged) and after discharge. Social: 1. Although the patient’s informal social support seems to be adequate, her son and sister may not be able to provide all of her needs during her recovery from this acute illness. The patient’s primary care physician will be contacted in order to preserve continuity of care. The patient has long-term insurance, but it is not expected to need it at this time. 2. Despite the expectation of full resolution, the son will be educated about the seriousness of his mother’s condition. He will be asked to bring a copy of her advance


of 193

directives. We will discuss do-not-resuscitate (DNR) with the son as the patient does not currently have decision-making capacity. Her prior wishes state “no artificial prolongation of her life should be attempted if she has a terminal illness”, but there is no terminal diagnosis at this point. Eventually dementia may become a terminal condition, but she is probably far from that point. If she does progress to dementia and continues to lose weight, a discussion about permanent artificial feeding should take place. The son will have to be educated about the fact that feeding tubes have not been shown to prolong life on average, although anecdotal cases report prolonged survival. 3. The patient’s son may be at risk for caregiver burden. If she fails to recover to her previous functional status, her son should be encouraged to enroll a caregiver support group or some other source of support in order to fight caregiver burnout.


of 193

Station 1: Helpful guidelines for scoring THE PHYSICIAN'S ROLE IN AN INTERDISCIPLINARY TEAM The physician plays many roles on the interdisciplinary health care team. Often the physician acts as the convener of the team and the nexus of information flow. The physician collects pertinent patient information to aid in diagnosis and therapeutic planning. The physician’s role is one of prominence but not necessarily leadership. A well-functioning team is egalitarian; suggestions are generated by anyone and, in fact, team leadership should shift depending on the patient’s requirements. It is not unusual for a physician to turn over the care of a patient to another team member, and then, when appropriate, for the team member to return the care of that patient back to the physician. The physician on an interdisciplinary team interfaces with five distinct groups:

• Other team members • Students • Patients • Families • Caregivers

Other points 1. Responsibilities to team members don't differ according to discipline. They involve cooperation and participation in the tasks at hand and respect for the contribution of others. 2. The physician should teach these behaviors to students as well as model them. The physician should serve as a mentor to not only physicians-in-training but to students from all disciplines. 3. The physician should ensure that medical issues are given the proper weight in the decision-making process. He or she can accomplish this by describing the relevant medical aspects of cases so that they are fully understood by all participating in the development of the interdisciplinary care plan.

of 193

Station 2: Performance-Oriented Mobility Assessment Issue Administering and scoring the Performance-Oriented Mobility Assessment Presenting Situation One patient who can ambulate safely enough to undergo the POMA either in the inpatient or outpatient setting (GEM unit, Nursing Home, primary care clinic, home care) Activity Administer, score and interpret the POMA Time Required 30 minutes This station was developed by Marcos Milanez, MD Props Blank POMA scoring form


of 193

Station Number 2 You will be observed by a geriatrics attending while you administer, score and interpret the Performance-Oriented Mobility Assessment (POMA) in one patient who can ambulate safely enough to undergo the POMA. The scoring form will be provided to you.


of 193


Checklist: POMA Station 2

Date: Fellow: SP initials

Yes No

1. Introduced POMA properly

2. Chose an armless chair

3. Marked the correct distance for the gait test

4. Correctly instructed the patient

5. Safely guarded the patient

6. Documented the results of the test, include floor surface and walk time

7. Demonstrated the task when needed (side-by-side standing balance; semi-tandem/tandem; toe stand/heel stand)

8. Correctly scored at least 80% of the items

9. Linked the results of the POMA to the patient’s H&P

10. Documented the interpretation of the results Comments or Clarifications:


of 193

How would you rate the fellow's ability to perform the POMA in older persons?

Excellent

Good

Fair

Inadequate

Poor




of 193

Station 2: POMA Scoring Form Balance Place a hard armless chair against a wall. The following maneuvers are tested: 0 1 2 Score 1. Sitting down unable without help or collapses

(plops) into chair or lands off center of chair

able and does not meet criteria for 0 or 2

sits in a smooth, safe motion and ends with buttocks against back of chair and thighs centered on chair

0 1 2

2. Sitting balance unable to maintain position

(marked slide forward or leans forward or to side)

leans in chair slightly or slight increased distance from buttocks to back of chair

steady, safe, upright 0 1 2

3. Arising unable without help or loses

balance or requires > three attempts

able but requires three attempts able in ≤ two attempts 0 1 2

4. Immediate standing balance (first 5 seconds) unsteady, marked staggering,

moves feet, marked trunk sway or grabs object for support

steady but uses walker or cane or mild staggering but catches self without grabbing object

steady without walker or cane or other support 0 1 2

5. Side-by-side standing balance sec__ unable

or unsteady or holds ≤ 3 seconds

able but uses cane, walker, or other support or holds for 4–9 seconds

narrow stance without support for 10 seconds 0 1 2

6. Pull test (person at maximum position attained in #5, examiner stands behind and exerts mild pull back at waist) begins to fall takes more than two steps back fewer than two steps backward and

steady 0 1 2

7. Able to stand on right leg unsupported sec__ unable

or holds onto any objects or able for < 3 seconds

able for 3 or 4 seconds able for 5 seconds 0 1 2

8. Able to stand on left leg unsupported sec__ unable

or holds onto any object or able for < 3 seconds

able for 3 or 4 seconds able for 5 seconds 0 1 2

9. Semi-tandem stand sec__ unable to stand with one foot half

in front of other with feet touching or begins to fall or holds for ≤ 3 seconds

able for 4 to 9 seconds able to semi-tandem stand for 10 seconds 0 1 2

10. Tandem stand sec__ unable to stand with one foot in

front of other or begins to fall or holds for ≤ 3 seconds

able for 4 to 9 seconds able to tandem stand for 10 seconds 0 1 2

11. Bending over (to pick up a pen off floor) unable

or is unsteady able, but requires more than one attempt to get up

able and is steady 0 1 2


of 193

12. Toe stand unable able but < 3 seconds able for 3 seconds 0 1 2 13. Heel stand unable able but < 3 seconds able for 3 seconds 0 1 2 BALANCE SUBTOTAL /26

Gait Person stands with examiner, walks down 10-ft walkway (measured). Ask the person to walk down walkway, turn, and walk back. The person should use customary walking aid. 1. Type of surface type: ____

1 = linoleum or tile; 2 = wood; 3 = cement or concrete; 4 = other____________

not included in scoring

0 1 2 Score 2. Initiation of gait (immediately after told to “go”) any hesitancy or multiple

attempts to start no hesitancy 0 1

3. Path (estimated in relation to tape measure). Observe excursion of foot closest to tape measure over middle 8 feet of course. marked deviation mild or moderate deviation or

uses walking aid straight without walking aid 0 1 2

4. Missed step (trip or loss of balance) yes, and would have fallen

or more than two missed steps yes, but appropriate attempt to recover and no more than two missed steps

none 0 1 2

5. Turning (while walking) almost falls mild staggering, but catches

self, uses walker or cane steady, without walking aid 0 1 2

6. Step over obstacles (to be assessed in a separate walk with two shoes placed on course 4 feet apart) begins to fall at any obstacle

or unable or walks around any obstacle or > two missed steps

able to step over all obstacles, but some staggering and catches self or one to two missed steps

able and steady at stepping over all four obstacles with no missed steps 0 1 2

GAIT SUBTOTAL /9 TOTAL /35

Adapted from AGS Geriatrics at your Fingertips and Mary E. Tinetti, MD.

of 193

Station 3: Counseling about Preventive Care Issue Preventive Care Presenting Situation A patient who has not seen a physician in 3 years presents to your outpatient clinic. The fellow should recommend appropriate preventive measures for her. Activity Patient encounter Time Required 15 minutes This station was developed by Jorge Ruiz, MD


of 193

Station Number 3 Setting: Physician’s office You are about to see Mrs. Lozano, a 65-year-old woman who has just moved to the area to be closer to relatives. She was last seen by a primary care doctor 3 years ago but has been to the ophthalmologist recently. At the time of her last PCP visit, she had a mammogram and a Papanicolau. She is independent in all ADLs and IADLs, and her MMSE is 29/30. She has a history of osteoarthritis for which she takes acetaminophen and mild hypertension which is well controlled on hydrochlorothiazide. She smokes one pack a day for over 20 years but does not drink alcohol. Mrs. Lozano has completed a living will and a durable power of attorney for health care. Her vital signs are within normal limits. You have done a complete physical examination with exception of the gynecological, breast, and rectal exam. The exam up to that point is non-revealing. Task: Please counsel Mrs. Lozano about preventive health measures.


of 193


Checklist: Preventive Care Station 3


Yes No

1. Smoking cessation counseling/medication

2. Exercise counseling

3. Dietary modification counseling

4. Hearing screen: Subjective questions

5. Hyperlipidemia screen: Lipid panel (LDL and HDL cholesterol and triglycerides)

6. Osteoporosis screen: Bone mineral density test

7. Colon cancer screen: o FOBT o Flexible sigmoidoscopy (every 5 years) o Double-contrast barium enema (every 5-10 years) o Flexible sigmoidoscopy with FOBT (every year) o Flexible sigmoidoscopy with double-contrast barium enema (every 5-10 years) o Colonoscopy (every 10 years)

8. Breast cancer screen o Mammogram o Clinical breast examination o Breast self-examination

9. Cervical cancer screen: Papanicolau test

10. Dental health screen: Oral cavity examination

11. Skin cancer screen: Skin checks by experienced provider (in high-risk group); sunscreen

12. Immunizations: o Influenza o Pneumonia o Tetanus updates

Comments or Clarifications:


of 193

1. How would you rate the

candidate's communication skills?

Excellent

Good

Fair

Inadequate

Poor

2 How would you rate the candidate's ability to address preventive issues in this case?

Excellent

Good

Fair

Inadequate

Poor




of 193

Station 3: Standardized Patient Script

Your name is Marcia Lozano. You portray a 65-year-old woman who has just moved to the area to be closer to relatives. You are overdue for and receptive to all services recommended by the National Cancer Institute for women ages 65 to 70 years with the exception of Papanicolau tests and pelvic and rectal examinations.

You have not had health care contact for more than 3 years except for receiving a free Papanicolaou test 6 months earlier at a community clinic. You have no specific symptoms or concerns and state that you wish to establish care with a primary care physician as part of relocating to the area.

You do not have a personal history of cancer or of having a breast biopsy. If asked, you state that you smoke a pack a day for the past 20 years, have previously quit twice, and are interested in trying to quit again. You are within 20% of your ideal body weight. If asked, you will give a high-fat, low-fiber dietary history and a family history of a mother with breast cancer and a grandfather with colon cancer.

Services indicated include clinical breast and oral cavity examinations and recommendations to have mammography, undergo sigmoidoscopy or colonoscopy, quit smoking, do monthly breast self-examination, return fecal occult blood tests, increase dietary fiber, and decrease dietary fat. None of these services was explicitly requested by you except the clinical breast examination, which you will request at the end of the encounter if the physician did not spontaneously provide one.

You will decline a Papanicolaou test and pelvic examination if the physician advises them at that visit but agree to a future appointment for those purposes. If the physician advises a rectal examination, you will also decline stating that you recently had a "flare-up" of hemorrhoids that had just improved and that you don’t want to risk irritating them. You will also refuse serum cholesterol and other laboratory tests as well as immunizations if offered, explaining that you anticipate getting health insurance shortly and want to defer these expenses for now. The exception was urinalysis if it was part of the physician's routine orders before seeing the patient. Prompts are used to standardize the scenario and give all candidates an opportunity to address relevant issues. PROMPT 1 (at the end of the encounter, if not asked): Can you order a mammogram? PROMPT 2 (Doctor asks for a PAP): I have hemorrhoids and I am really sore, can we do it next time? PROMPT 3 (at the end of the encounter, if not asked): My friend is taking aspirin. Do I need aspirin, Doctor?

of 193

Station 4A: Telephone Medicine Issue Managing nursing home patients over the phone Presenting Situation The fellow is on call for a community nursing home this weekend. At 10 pm, the nurse calls to inform the physician that a patient is not eating and reports abdominal pain. Activity Demonstrate skills in managing telephone triage in long-term care Time Required 15 minutes This station was developed by Juan Carlos Palacios, MD


of 193

Station Number 4A Setting: Nursing Home – telephone call A nurse from a community nursing home calls you to report that a nursing home patient, Mr. Robert Jones, is not eating and reporting abdominal pain. You are covering the nursing home, and no other information is available to you prior to this phone call. This facility has basic diagnostic resources (laboratory and X-rays). Task: Please obtain the information you need and convey your recommendations regarding his plan of care.


of 193


Checklist: Telephone Station 4A

Date__________ Fellow_______________________________ SP initials _________

Yes No

1. Asked about vital signs

2. Asked about patient’s past medical history

3. Asked about patient’s past surgical history

4. Asked about current medications

5. Asked about the intensity, duration, radiation, aggravating and relieving factors

6. Asked about associated symptoms such as diarrhea, nausea, vomiting, constipation, SOB, CP, dizziness, sweating

7. Asked pertinent history such as gallbladder or kidney stones

8. Asked about other pertinent physical findings such as testicular pain (testicular torsion)

9. Asked about the last BM and blood in the stools (possible bowel ischemia)

10. Requested evaluation of peripheral pulses (possible AAA)

11. Requested the last INR (intra-abdominal bleeding)

12. Transferred the patient to ER for further evaluation

TOTAL



of 193

1. How would you rate

the candidate's communication skills?

Excellent

Good

Fair

Inadequate

Poor

2. How would you rate the candidate's clinical ability to manage abdominal pain over the phone?

Excellent

Good

Fair

Inadequate

Poor

Station 4A Assessment Pass Fail



of 193

Station 4A: Standardized Patient Script Your name is Michael Yates/Laura Smith. You are an RN working on the night shift in a community nursing home. There is a shortage of nurses tonight because one of the nurses is sick. You are in charge of the whole unit. You are calling the doctor because at the time of report it was mentioned that Mr. Robert Jones had been reporting abdominal pain and lack of appetite since this morning. Due to your multiple obligations tonight, you have limited time to assess Mr. Jones. You know that Mr. Jones is a 78-year-old male nursing home resident for the past 2 years. He was admitted initially to the nursing home because of a right MCA stroke that resulted in left hemiparesis. He has a history of hypertension, coronary artery disease, congestive heart failure, atrial fibrillation, diabetes, hyperlipidemia, osteoarthritis, COPD and gout. He failed rehabilitation after 6 weeks in a skilled nursing facility. His current medications are: lisinopril 10 mg daily metformin 1000 mg twice daily warfarin 5 mg every night simvastatin 80 mg at bedtime atenolol 25 mg daily furosemide 40 mg daily digoxin 0.125 mg daily albuterol/ipratropium MDI 2 puffs q 6 hrs as needed Mr. Jones’ mental status has fluctuated while in the nursing home. He is sometimes confused but appropriate at other times. You know that he has been feeling withdrawn since this morning. He has not been eating well and he did not eat dinner while you where there. You briefly evaluated him. He did not look short of breath. He was not wheezing. Vital signs were temperature 98 F, pulse 100, BP 110/74 and RR 24. When asked about pain, he pointed to his whole abdomen. You attempted to obtain more information about the type of pain, but he thought that you were his son and described an old tale from the time his son was a child. You felt his stomach and noticed that there was diffuse mild tenderness on palpation. You do not know of any trauma or falls reported by the previous shift. No history of kidney stones or gallstones. Testicles seemed to be without any swelling or redness. The pulses were symmetric and 1+ on all extremities. Foley catheter showed cloudy and pink urine.


of 193

Station 4A: Standardized Patient Script (continued) Nurse: Doctor, I am calling because Mr. Jones, a 78-year-old male resident of our nursing home, is reporting some abdominal discomfort and not eating well. Possible pertinent questions from the fellow and your corresponding answers: What are his vital signs?

His temperature is 98 F, pulse 100, BP 110/74 and RR 24. What is the patient's medical history? Mr. Jones is a 78-year-old male nursing home resident for the past 2 years. He

was admitted initially to the nursing home because of a right MCA stroke that resulted in left hemiparesis. He has a history of hypertension, coronary artery disease, congestive heart failure, atrial fibrillation, diabetes, hyperlipidemia, osteoarthritis, COPD and gout. He failed rehabilitation after 6 weeks in a skilled nursing facility.

What medications is the patient on? lisinopril 10 mg daily

metformin 1000 mg twice daily warfarin 5 mg every night simvastatin 80 mg at bedtime atenolol 25 mg daily furosemide 40 mg daily digoxin 0.125 mg daily albuterol/ipratropium MDI 2 puffs q 6 hrs as needed

What is usual mental status? His mental status has fluctuated while in the nursing home. Sometimes he is confused but other times appropriate. Doctor, today he thought I was his son.

How long he has had the abdominal pain? Doctor, it was reported to me that he has been different, more withdrawn since this morning. He has not been eating well; he did not eat any dinner for me.

Does the patient look dizzy, clammy, or sweaty? No, not really. Has the patient had a fever? No. Does he have any shortness of breath or chest pain?

No. Any history of trauma? No falls or trauma. Has he had any blood in the stools, black, tarry stools or bleeding from the rectum?

No. His last bowel movement was 2 days ago. How is the pain?

It was difficult to obtain a description because of his mental status, but when I evaluated him he was holding and touching his abdomen.


of 193

Station 4A: Standardized Patient Script (continued) Does the pain radiate?

It is hard to obtain information from him, but his abdomen is mildly tender on palpation.

Any associated symptoms? No nausea or vomiting. Any aggravating or relieving factors? I don’t think so. Is there a history of kidney stones? No. Is there a history of gallstones? No. Are his testicles painful? They seem to be okay. No swelling or redness. When was the last bowel movement? Two days ago. Is there a history of back pain, atherosclerosis or stroke? Did you check peripheral pulses?

He has a history of stroke and CAD. Pulses are 1+ symmetric. Is there any urinary frequency, urgency or changes in the urine (blood or cloudiness)?

He has a Foley catheter, and his urine is cloudy and pink. What was his last INR? Two days ago, it was 2.6.

of 193

Station 4B: Telephone Medicine Issue Managing elderly, community-dwelling patients over the phone Presenting Situation The fellow is on call for the primary care clinic. A patient calls seeking advice for flu-like symptoms. Activity Demonstrate skills in managing telephone triage in outpatient care Time Required 15 minutes This station was developed by Juan Carlos Palacios, MD


of 193

Station Number 4B Setting: Geriatric Clinic – telephone call Mr. Joshua Simpson is a patient from the Geriatric Clinic. He has been experiencing "flu like" symptoms for the past 5 days. He has called the answering service to talk with the doctor on call about his symptoms. Task: Please obtain information and convey your recommendations regarding the plan of care.


of 193


Checklist: Telephone Station 4B

Date_________ Fellow_______________________________ SP initials_______

Yes No

1. Asked about patient’s medical history

2. Asked about current medications

3. Asked about any fever

4. Asked about the duration of the cough and associated symptoms: How long? How often? Characteristics of the sputum? Affecting sleeping?

5. Asked pertinent questions about wheezing: How long? Severity? Positional? Prior base line? Medications?

6. Established that chest pain is an associated symptom

7. Asked about location, radiation of chest pain

8. Established if chest pain is present now

9. Asked about associated symptoms such as sweating, nausea, dizziness, difficulty breathing

10. Elicited from interview red flag symptoms such as syncope or shortness of breath

11. Determined if any history of CAD or angina

12. Asked about pain than can be elicited with pressure or inspiration

13. Asked questions to determine the severity of SOB

14. Asked about SOB and association to body position

15. Asked about prior baseline SOB

16. Scheduled the patient for a close f/u within 24 hrs in the clinic

17. Discussed and educated patient about possible warning symptoms that need to be evaluated immediately in the ER

TOTAL


of 193

1. How would you rate the candidate's communication skills?

Excellent

Good

Fair

Inadequate

Poor

2. How would you rate the candidate's clinical ability to manage patients with respiratory problems over the phone?

Excellent

Good

Fair

Inadequate

Poor

Station 4B Assessment Pass Fail



of 193

Station 4B: Standardized Patient Script

Your name is Joshua Simpson. You have been a patient of the Geriatric Clinic for the past ten years and are annoyed by the constant change of doctors and the lack of continuity of care.

You are a 75-year-old male who lives alone. You have been feeling sick for the past few days so you called the answering service to talk with the doctor about your symptoms. History of Present Illness

You have been experiencing "flu like" symptoms for the past 5 days. You have been "feeling bad" and "under the weather". This episode started with a runny nose and malaise, but now you have a cough and a subjective fever (you did not take your temperature). At the advice of a friend, you bought Robitussin DM over the counter for your symptoms without much benefit.

Your cough has been present for the past 2-3 days, it keeps you up at night, and you are expectorating yellowish to clear sputum. You have felt very mildly short of breath for the past 3 days which is not worsening or associated with lying down. You mainly notice it with exercise.

You have also noticed some wheezing, again mainly with exercise, however, you have had wheezing for the past few years. At this time the wheezing is worse than your baseline. Prior doctors explained that the wheezing was due to long term smoking. You sporadically use an inhaler prescribed a few years ago which provides some relief of the wheezing.

You have also been experiencing some chest pain that is very difficult to describe, "all over your chest", not associated with shortness of breath, nausea, vomiting, dizziness, or sweating. You have no history of prior coronary disease, myocardial infarction, pulmonary embolism, or congestive heart failure. You have noticed that coughing, pressing on your chest, or moving your arms exacerbate the pain. Past Medical History

Your history includes a right MCA stroke 5 years ago, initially causing left hemiparesis which resolved after several months of physical therapy. You also have hypertension, diabetes, and COPD due to smoking one pack per day since age 18. After the stroke, you quit smoking at the recommendation of the medical staff. Medications metformin 1000 mg twice a day hydrochlorothiazide 25 mg daily aspirin 325 mg daily albuterol/ipratropium 2 puffs every 6 hrs as needed


of 193

Station 4B: Standardized Patient Script (continued) Patient: Doctor, I am calling you because I am not feeling well. For the past 5 days I have felt "under the weather". Possible questions from the fellow and suggested answers: What is the problem?

I have a cough. FOLLOW ALGORITHM FOR COUGH Do you have shortness of breath?

Yes, a little. FOLLOW ALGORITHM FOR SOB Are you wheezing?

Yes, a little. FOLLOW ALGORITHM FOR WHEEZING Do you have any chest pain?

Yes, all over my chest. FOLLOW ALGORITHM FOR CP Do you have a fever?

Yes. I have felt warm all day, but I did not take my temperature. Do you have any lung disease?

Yes. I have COPD. Do you have pain in your sinus areas?

Yes. I have a headache, and my sinuses feel heavy. Do you have a runny nose?

Yes, I did at the beginning of this illness a few days ago. Are you taking any medications for your symptoms?

Yes, Robitussin DM. I don’t think it is helping. General Prompts If about half way through the interview, the fellow has not addressed certain areas and seems a bit off track, you can give some general prompts to help him/her remember to ask about cough, shortness of breath, wheezing, or chest pain. Cough How long has the cough been present?

I would say for the past 2-3 days. How often do you cough?

Several times a day. Does the cough keep you up at night?

I think so. I have not been sleeping well. Are you raising any phlegm or sputum?

Yes, it is yellowish. No blood. What are your medical conditions?

I have COPD, hypertension, and diabetes.


of 193

Station 4B: Standardized Patient Script (continued) Shortness of breath How long have you felt short of breath? About 3 days, I think. Is it getting worse?

No. Are you comfortable with simple conversation?

Yes, I can talk and walk without any problem. How much different is your breathing from your usual pattern (baseline)?

I think it may be a little worse. Does the shortness of breath come and go?

No. Are you short of breath in certain positions, such as when you are lying down?

No. Wheezing How severe is your wheezing?

It happens only when I exercise. Is it getting worse?

No. When did it start?

I have had wheezing for a long time. I think it is worse the past few days. Before this episode, have you had any problems with your lungs?

Yes doc, I have COPD. Another doctor told me that it was because of my smoking. In any case, I don't smoke anymore.

Do you use any medications for COPD? Yes, I use a pump. I don't use it frequently. I don't remember the name.

Does the inhaler help? Have you been using it? I have used it 3-4 times a day for the past few days and it helps me.

Chest pain Do you feel the chest pain now? Yes. Where is it?

Doc, it is difficult to say. It’s all over my chest. Is it in the middle of the chest, crushing, pressing or radiating to the arm?

No. Is it associated with sweating, shortness of breath, nausea or dizziness?

No. Do you have coronary disease, prior heart attacks, or chest pain in the past?

No.


of 193

Station 4B: Standardized Patient Script (continued) Does the pain occur at rest or with minimal exertion?

No, it is just there. Have you fainted? No. Do you have any history of congestive heart failure or pulmonary embolism?

No. Does taking a deep breath make the pain worse?

I think so. Has the chest been injured?

No. Does moving the arm reproduce the pain?

Yes, maybe. Does pressing on the chest reproduce the pain?

Yes, maybe.

of 193

Station 5: Withholding & Withdrawal of Treatment Issue Withholding & Withdrawal of Treatment Presenting Situation A patient with locally advanced lung cancer is on a ventilator due to respiratory failure associated with pneumonia and malignant effusion. You have been her primary care physician for the past 2 months but have never met her family. She is comatose, and there is no hope of recovery. The fellow will discuss end-of-life issues with the patient’s husband and health care surrogate. The main goal is to discuss the removal of the ventilator. Activity Patient encounter Time Required 15 minutes This station was developed by Khin Zaw, MD


of 193

Station Number 5 Setting: Hospital waiting room. You are about to meet Mr. Warren Smith, husband and healthcare surrogate of Mrs. Smith who is a 69 year-old Caucasian female. You diagnosed her with locally advanced lung cancer two months ago. Since then, you have been her primary care physician but have never met her family. She underwent one cycle of chemotherapy 4 weeks ago with no improvement. Instead, her functional status declined significantly when she developed community acquired pneumonia and malignant pleural effusion, requiring ventilator support for one week. Her liver and renal functions are deteriorating rapidly. She has been unresponsive for the past 3 days. Both MICU attending and oncologist agree that she has no chance of survival. Mrs. Smith completed a living-will which states “no heroic measures” in case of terminal conditions or persistent vegetative state. Currently, she is full code. Prior to her recent illness, Mrs. Smith lived with her husband at home independently. Her past medical history includes hypertension and osteoarthritis. She has a 50-pack year history of cigarette smoking and quit about 3 years ago. She was otherwise healthy and active. Your intern told you that her husband is “difficult.” Task: Please discuss with Mr. Warren Smith the withdrawal of ventilator support.


of 193


Checklist: Withholding & Withdrawal of Treatment Station 5


Spikes Protocol Yes No Informing Surrogate

1. Sat down in order to be at eye level with the surrogate. Asked if family members or others should be present (CLASS protocol)

2. Asked an open-ended question to elicit what the surrogate understands about the patient’s health situation: include decisional capacity □ medical information (diagnosis, prognosis) if necessary □ discuss possible treatment options □ discuss risk/benefits of each option

3. Appropriate use of SPIKES protocol and NURSE mnemonic

Patient’s Preferences

4. Explore and interpret advance directives if there are any. Explore and interpret prior values and wishes if no advance directives: Ask “What does the patient value the most?” □ Ask “What would the patient have wanted?” □ Ask “Any previously stated wishes?” □

Views of Family (& Caregivers)

5. Explore their understanding & interpretation of: patient’s medical condition (including prognosis) and patient’s preferences (ACP, values and wishes)

6. Explore their views: family members other than surrogates and their positions; convergent or divergent views on patient’s condition

Legal, Administrative and External Factors

7. Explore legal and ethical implications: state statues or case law that apply to this situation and hospital policy and guidelines for this situation

Establishing Goals of Care

8. Identify and resolve dilemma

9. Clarify decision making hierarchy (what decision is based on): patient’s current wishes, substituted judgment and beneficence

10. Establish overall goals of care (Big Picture Goals): cure disease, prolong life, maintain function, or provide comfort

Establishing Plan of Care

11. Types of treatment that may be limited: ventilator support, CPR, AHN, blood products

12. Explain how treatment will be limited: what are steps, what to expect, make a plan: when and how □ agreement on the plan □

Summarize

13. Summarize information: simple and focused, avoid lecture Comments or Clarifications:


of 193


Excellent

Good

Fair

Inadequate

Poor

2 How would you rate the candidate's ability to discuss W/W of life support?

Excellent

Good

Fair

Inadequate

Poor




of 193


Your name is Warren Smith, husband and health care proxy for Mrs. Diane Smith. Your wife is a 69 year-old Caucasian female who was diagnosed with locally advanced lung cancer about 2 months ago by her primary care physician. Subsequently, she was evaluated by an oncologist and underwent one cycle of chemotherapy about 4 weeks ago. You noted she had become progressively weaker and lost her appetite. Approximately 2 weeks ago, she appeared ill, felt warm, and began coughing. She reported some shortness of breath. You rushed her to the ER, and she was admitted.

You were very concerned that she appeared worse, but you were assured by the medical team that your wife was getting “the best” treatment. You received a phone call from a medical intern during the night a week ago asking you to give permission to intubate her – “to help her breathe.” You were told that her pneumonia was worsening and that she had developed a fluid collection in her chest. You also consented for draining the fluid out for testing and symptom relief.

In the MICU, your wife tried to tell you something while intubated, but you could not understand. Later, you could not communicate with her any longer because she required sedation. For the past 3 days, she has been unresponsive.

Your wife has completed a living-will which states “no heroic measures” in case of terminal conditions or persistent vegetative state. Since she started getting ill, you haven’t had a chance to talk to your wife to discuss with her goals of care in detail. She briefly told you that she doesn’t want to be “hooked on a machine.”

You have no immediate family members except an estranged son, Jack Smith, who lives in California. Neither of you have had contact with him for many years.

You are frustrated that you haven’t heard anything from the medical team yet or the information you received was incompletely explained to you. Prompts are used to standardized the scenario and give all candidates an opportunity to address relevant issues. PROMPT 1: (by 3-4 minutes)

If candidate does not ask about other family members: We have a son in California. You know.

PROMPT 2: (by 7-8 minutes) If candidate does not establish goals of care: Doc. You should better guide me. Making her comfortable?

PROMPT 3: (by 7-8 minutes) If candidate gives you choices without recommendations (no guidance): You are the doctor! Please tell me what I should do.

PROMPT 4: (by 10 minutes) If candidate does not explain steps in withdrawal of ventilator: You just pull the plug and let her suffer?

of 193

Station 5: Standardized patient script (continued) and helpful guidelines for scoring

Context Explanation & Examples SP Possible Responses Informing Surrogate

1. Assess decisional capacity □ Confirm surrogate (or) legal guardian □ Presence of other surrogates (or) legal guardians □

Candidate confirms surrogate and presence of other surrogates. Candidate explains patient’s lack of decision making capacity (based on the case).

“Yes, I am her husband and her proxy (for health care). Our son is in California, but we haven’t spoken for many years. He wants nothing to do with us.”

2. Update medical information (diagnosis, prognosis) □ Discuss possible treatment options □ Discuss risk/benefits of each option □

Candidate informs surrogate of her current condition and prognosis. Possible treatment options, benefits/risks, and outcomes are discussed

“Well, this is the first time I’ve heard this. I didn’t know she was that bad. They have been telling me all along that her cancer may be cured. I can’t believe it. Is there a cure? Tell me what the possibilities are.”

3. Use SPIKES protocol □ NURSE mnemonic □

Candidate displays appropriate use of SPIKES and NURSE.

Responds accordingly.

Discussing Patient’s Preferences 4. Explore and interpret advance

directives:

“Does she have any advance directives?” “Does she have a living will?” “Do you understand what ‘heroic measures’ mean?”

“What are advance directives?” After candidate explains, you may say, “She has a living will. I gave it to you already.”

5. Explore and interpret patient’s prior values and wishes if no advance directives:

“What does your wife value the most?” “Can you explain it to me more?” “What would she have wanted or what would she do in a situation like this?” “Did she ever mention her wishes before she got sick or any other time?”

“My wife values life. She often said, life is God’s gift and precious. My wife said, ‘if you are against life you are against God.’ But she told me a few weeks ago that she didn’t want to be hooked to machines. She remembered the bad experiences that my mom had 5 years ago. I am sure she wouldn’t want to suffer.”

Explore Views of Family (& Caregivers) 6. Explore their understanding (& their

interpretation) of: Patient’s medical condition (including prognosis) □ Patient’s preferences (ACP, values and wishes) □

“Do you fully understand your wife’s condition?” “What do you understand about what her living will says?”

“I know she has been sick with the cancer. But I didn’t know how bad it was until now. I still think she may be cured.” Show ambiguity: “I am not really sure. She values life very much, but she doesn’t want to suffer.”

7. Explore their views: Family members other than surrogates and their positions □ Convergent or divergent views on patient’s condition □

“Is there anyone else in your family who might be concerned about her?” If there is someone: “What would your (son) think about all this? Have you had a chance to discuss it with him?”

You may say, “I have not had any contact with my son for a long, long time.”


of 193

Legal, Administrative and External Factors 8. Explore legal and ethical implications:

State statues or case law that apply to this situation □ Hospital policy and guideline on this situation □

Candidate is expected to alleviate concerns and fears regarding W/W: withdrawing and withholding unwanted and burdensome treatment is ethically, morally and legally sound. Withdrawing is equivalent to withholding. Candidate should state that the medical team is responsible for withdrawing the ventilator, not the surrogate who only gives consent (not an order). Hospital guidelines and policy are available.

When candidate recommends withdrawing life support; i.e. ventilator removal, ask: “It sounds like Terri Schiavo, right? You pull the plug.” “I don’t want to be the one who orders to kill her. I will have to live with this guilt all my life.” You expect candidate to explain W/W does not equal killing or criminal homicide. “I wonder if the state will be after me.”

Establishing Goals of Care 9. Identify and resolve dilemma □ Candidate is expected to resolve concerns

during the discussion. Above concerns resolve after candidate’s explanation.

10. Clarify decision making hierarchy (what decision based on): Patient’s current wishes □ Substituted judgment □ Beneficence □

Candidate is expected to help surrogate in formulating goals of care. In this case, the decision will be based on substituted judgment – her living will and her previously stated wishes and to a certain extent, what is in her best interest.

You agree with candidate who guides you by establishing goals of care. If candidate asks you to decide (on your own) by saying – “You decide what you want me to do.” Then, say “I don’t know doc. I am afraid that I can’t make this kind of decision.”

11. Establish overall goals of care: Curative □ Function □ Comfort □ See above. Establishing Plan of Care

12. Types of treatment that may be limited: Ventilator support □ CPR □ AHN □

Candidate to discuss withdrawal of the ventilator and code status at minimum.

“When you remove the tube, will my wife have difficulty breathing?”

13. Explain how treatment will be limited: What are steps □ What to expect □ Make a plan: when and how □ agreement on the plan □

Candidate to formulate steps in withdrawal of ventilator support, to discuss what to expect after removing ET tube, and to describe how to manage post extubation.

“What is going to happen if she becomes short of breath? Will she need to be re-intubated?” When candidate mentions morphine (opioids) and lorazepam (benzodiazepine) to manage SOB post extubation, you may ask: “Will the morphine cause her to die (quicker)?”

Summarize 14. Summarize information □ simple and

focused □ avoid lecture □ Candidate to summarize discussion. You agree with withdrawing ventilator support

and DNR/DNI status. Adapted from: 1. Prendergast TJ, Puntillo KA. Withdrawal of Life Support: Intensive Caring at the End of Life. JAMA 2002 Dec;288(21):2732-41. 2. Medical Oncology Communication Skills Training Learning Module 6: Conducting a Family Conference (2002).

of 193

Station 6: Delivering Bad News Issue Delivering bad news Presenting Situation A patient returns for follow up visit after a CT-guided biopsy of right lung mass one week ago. The fellow will inform him of a new diagnosis of lung cancer. Activity Patient encounter Time Required 15 minutes This station was developed by Khin Zaw, MD


of 193

Station Number 6 Setting: Physician’s office. You are about to see Mr. Miller who is an 82-year-old Caucasian male veteran, a widower, who lives alone at home independently. His past medical history includes hypertension and BPH. He has a 50 pack-year history of cigarette smoking and quit about 3 years ago. He is otherwise healthy and active. Approximately two weeks ago, you evaluated him for non-productive cough and weight loss of 10 pounds over a 3 month time period. Chest X-rays showed a 6 x 6 cm right lower lobe density suspicious for malignancy and moderately hyper-inflated lung fields. He underwent the CT-guided lung biopsy last week. The biopsy result reveals aggressive squamous cell carcinoma. Mr. Miller’s daughter, Nancy Smith, lives about 5 miles away from him. Task: Please inform Mr. Miller that he has lung cancer (deliver bad news).


of 193


Checklist: Delivering Bad News Station 6


Spikes Protocol Yes No Setting

1. Sat down in order to be at eye level with the patient. Asked the patient if family members or others should be present (CLASS protocol)

Perception

2. Identify what the patient already knows including misunderstanding/misconceptions

3. Explore current emotional state

Invitation

4. How much does the patient want to know? Is it a good time to discuss?”

Knowledge

5. Give “warning shot!”

6. Context and delivery of news: direct, brief, clear, avoid use of medical jargon, bite size and easily understood

7. Keep silence!!!

Empathy

8. Manner: appear empathetic, supportive

9. Explore what the news has meant to the patient

Summarize and Strategize

10. Summarize information: simple and focused, avoid lecture

11. Suggested follow-up plan: agreement on the plan

12. Explore patient’s level of understanding (what has been discussed): Invite questions. Apply “Ask-Tell-Ask” principle □ “I wish…” statement

13. Address immediate risks: medical and psychological Comments or Clarifications:


of 193


Excellent

Good

Fair

Inadequate

Poor

2 How would you rate the candidate's ability to deliver bad news?

Excellent

Good

Fair

Inadequate

Poor




of 193


Your name is Robert Miller. You are an 82 year-old Caucasian male veteran, a widower, who lives alone at home independently. You have high blood pressure (hypertension) and an enlarged prostate (BPH). In the past you smoked 2 packs per day for 25 years (50 pack years), but you quit about 3 years ago. You are otherwise healthy and very active – you walked 2 miles every day until recently. You are a retired real estate agent, and your recent MMSE score was 29/30.

Approximately 2-3 months ago, you noted a dry cough – no mucous, no blood; and weight loss of about 10 pounds since. Your doctor told you that there was a nodule on the chest X-ray. You are worried that this might be cancer. Your doctor arranged for a needle biopsy which was done last week. You came to see your doctor in his office today to find out the biopsy result. Except some persistent dry cough and weight loss, you are doing quite well. However, you are beginning to feel slight shortness of breath with exertion and fatigue with walking. Your daughter, Nancy Smith, lives about 5 miles away from you. She offered you to go with you for the appointment, but you declined and drove yourself to the office. However, she is available if you need her. Prompts are used to standardized the scenario and give all candidates an opportunity to address relevant issues. PROMPT 1: (by 3-4 minutes)

If candidate does not convey the test results within the first 3 minutes: Just tell me – what did the test show?

PROMPT 2: (giving bad news) If you have difficulty understanding; e.g. frequent use of medical jargon, indirect conversation, not getting to the point, or not giving bite-sized information: Sorry, I didn’t get it. I don’t understand what you are saying. I am getting confused. Can you please explain it to me again?

PROMPT 3: (summarizing and strategizing) If candidate does not address immediate risks: Well, I will just go home then, but I don’t know how I can get home. I am quite nervous.

of 193

Station 6: Standardized patient script (continued) and helpful guidelines for scoring

Spikes Protocol Explanation & Examples SP Possible Responses Setting

1. Greet appropriately □ show interest in patient □

Candidate greets appropriately and shows interest to the patient.

2. Maintain patient’s privacy □ Close the door and ensure privacy. 3. Arrangement: seated □

comfortable interpersonal distance □ accessible □

Candidate sits at approximately arm’s length from the patient to console if necessary.

4. Invite participants: spouse □ SO □ staff (RN/SW/Chaplain) □

“Do you want anyone to be with you?” “Do you mind if my nurse is with us?”

“I came here by myself.” “It is alright with me.”

5. Establish reason for visit □ “Do you know that this visit is to inform you about the biopsy result?”

“Your office called me and said you wanted to talk to me in person. I guess it may be about the test result. Is it serious?”

6. Make personal connection □ eye contact □ avoid interruption □

Candidate makes personal connection to the patient and keeps eye contact throughout the interview. Set pager on silent mode (or asked colleague to answer pager) and turned off cell phone.

Perception 7. Elicit: Ask “What does the patient

know?” □ “Can you please tell me what you know so far?” “Can you tell me what is going on with you (medically)?”

“The chest X-rays showed something in my right lung. Then you asked me to do the biopsy.”

8. Explore: Ask “Any misunderstanding or misconception?” □

“Do you understand why we did the biopsy?” “Do you recall why we did the test?”

“I don’t know exactly what’s going on. But I remember you told me there is a mass in my lung.”

9. Explore current emotional status □ “Are you worried or anxious?” “Kind of like that. But I hope for the best. I think everything is going to be okay.”

Invitation 10. Elicit appropriate for discussion □ “Is now a good time to discuss the results?”

“I like to share with you the results of your biopsy. Is that okay with you?”

“I guess so.”

11. Explore: Ask “How much the patient wants to know?” □

Candidate finds out how much information the patient wants. “Can you tell me how much you want to know?”

“I would like to know as much as I can. Just tell me straight.”


of 193

Knowledge 12. Give “warning shot!” □ “We have something serious to discuss ….. Do

you feel ready for this discussion?” “I guess so.”

13. Context and delivery of news: direct □ brief □ clear □ avoid use of medical jargon □ bite size □ easily understood □

“I’m afraid I have some bad news for you. The biopsy showed that you have cancer.” Using language that matches the patient’s level of education.

You become very quiet, look away and then say, “Well…what else?”

14. Keep silence!!! □ Stay quiet for at least 10-15 seconds – resist the urge to tell the patient how to feel. Give the patient time to absorb the information and respond.

You may stay quiet or become anxious or angry visibly.

Empathy 15. Appear empathetic □ state

empathetic statement □ appear supportive □ show non abandonment □

Candidate appears empathetic as indicated by body posture, tone of voice, facial expressions, and word choice as well as showing some sense of understanding of the impact of the bad news. Possible empathetic statements: “This must be disappointing to you” or “I can see how upsetting this is to you” or “I know this must be difficult for you.” Candidate shows support by expressing concern, articulating his understanding of the patient’s situation, expressing willingness to help, making statements about partnership, and most importantly, acknowledging the patient’s effort to cope. Supportive statement like: “I will be with you during this illness, no matter what happens.”

You may say, “Are you sure that it is cancer? Couldn’t it be something else?” When candidate assures you of the diagnosis, you may respond, “My daughter will be very upset. She is hoping that I will attend her daughter’s graduation in July. But, now…” Or, “I know that this was coming because of my smoking, but I didn’t expect it so soon.” You want to know if it is curable (not knowing its aggressive nature).

16. Explore what the news has meant to the patient □

“What is most troubling to you about having cancer?” “You said it frightened you?”

“Will I be able to attend my granddaughter’s graduation?” or “I’m not concerned about dying, but I don’t want to suffer. I am afraid that I will have pain and I will lose my mind.”

17. Use “I wish .............” statement □ “I wish I had better news for you.” Pause or sigh and be silent.


of 193

Summarize and Strategize 18. Summarize information □ simple

and focused □ avoid lecture □ After spending time to respond to the patient’s emotions, the candidate finds out his readiness to take the next step: “Now we are at a new place and we need to discuss what to do next.” Candidate summarizes previous conversation. If patient does not seem ready to proceed, physician schedules another appointment in a short time (a few days).

You recount the summarized information and plan rather incompletely. Await candidate to correct or fill in information. If candidate asks to call your daughter to relay information or to schedule another meeting to include your daughter, you agree.

19. Make a plan: e.g. tests, treatment, referral etc. □ agreement on the plan □

If patient is ready, candidate lays out a concrete plan. Discuss with the patient and agree on the plan.

20. Explore patient’s level of understanding □ encourage to ask questions □ apply “Ask-Tell-Ask” principle □

Candidate checks on the patient’s level of understanding of what has been discussed: “Does this make sense to you?” or “Are you clear about the next steps?” or “Can I clarify anything more?” Candidate encourages the patient to ask questions if not clear or appears confused: “Please let me know if you have any questions.” If no questions at this time: “Write down your questions or concerns so I can answer them next time” or “You can call me anytime.” Candidate applies “Ask-Tell-Ask” principle.

Show that you are somewhat confused and have a limited understanding about the disease (especially if candidate infuses you with lots of medical/technical information). Show that you are in an emotional state and not able to digest information well (cognitive channel is somewhat blocked). You want to know what the future might hold (i.e. prognosis) and are concerned about suffering and being a burden to your daughter.

21. Address immediate risks: medical □ psychological □

Candidate assesses and addresses any immediate medical and psychosocial risks such as extreme anxiety, risk for suicide, returning home alone, driving home safely, need for company, etc.

You deny suicidal ideation. You want your daughter to pick you up since you are quite anxious at this time.

22. Closure □ Candidate makes a closing statement. You thank him/her and are looking forward to see him/her again.

Adapted from: 1. Baile WF et al. SPIKES—A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer. The Oncologist 2000;5:302-311. 2. Medical Oncology Communication Skills Training Learning Module 2: Giving Bad News (2002).

of 193

Station 7: Discussing Do Not Resuscitate (DNR) Issue Discussing do not resuscitate (DNR) Presenting Situation A patient with NYHA Class III CHF whose health has gradually deteriorated over the past 5 years presents to the outpatient clinic. The fellow will discuss a DNR order with him. Activity Patient encounter Time Required 15 minutes This station was developed by Jorge Ruiz, MD


of 193

Station Number 7 Setting: Physician’s office. You are about to see Mr. Ruben Perez. He is a 69-year-old Hispanic male who comes to the office for follow up of his congestive heart failure, hypertension, and osteoarthritis. He was recently admitted to the hospital because of pulmonary edema. He was discharged home after 3 days. He is taking lisinopril, furosemide, baby aspirin, metoprolol, and acetaminophen. He seems to be well controlled but he has been admitted twice in the last 2 years for CHF exacerbations. You just have obtained a history and conducted a directed physical examination. His vital signs are stable. There is a durable power of attorney in the chart but no DNR order or living will. You are now his doctor as his former PCP has just retired. Task: Discuss a DNR order with the patient.


of 193


Checklist: Discussing DNR Station 7


Yes No

1. Sat down in order to be at eye level with me. Asked if family members or others should be present (CLASS protocol)

2. Asked an open-ended question to elicit what I understand about my current health situation

3. Asked about my expectations for the future, general preferences and values regarding medical care

4. Established the context in which resuscitation would be considered

5. Described CPR as an intervention that might be needed

6. Told me I would die if I had a cardiac arrest and did not have CPR; told me I still might die even if I received CPR during a cardiac arrest

7. Gave me a numerical estimate of the chances of successful CPR

8. Asked me questions to be sure I understood what he/she told me about CPR

9. Elicited my preferences for CPR

10. Asked me to sign yellow Florida DNR form

11. Acknowledged that talking about DNR can be upsetting

12. Encouraged me to ask questions

13. Showed interest in how my decision might impact my personal life Comments or Clarifications:


of 193



Excellent

Good

Fair

Inadequate

Poor

2 How would you rate the candidate's ability to address DNR in this case?

Excellent

Good

Fair

Inadequate

Poor




of 193


Your name is Ruben Perez. You are a happily married man with 2 children. You have a 5 year history of heart failure ("heart problems"). You have been deteriorating over the last 2 years. You can go outside and perform most activities of daily living but walking more than two blocks leaves you short of breath. You have a long-standing history of hypertension and osteoarthritis. You are a former smoker.

Two weeks ago you were admitted to the hospital with pulmonary edema. You have had at least two admissions in the last 2 years for the same problem. You are in the office of your new physician; you are awake, alert, and aware. Your understanding of DNR is that it's an order you put on the chart to stop them from sticking tubes in you and shocking you and that it would prevent you from needlessly suffering. You have seen people undergoing CPR on TV.

Your have completed a durable power of attorney because your wife insisted, but you do not really care much about discussing dying issues with your family. You have had thoughts about death, but you do not like to discuss them with your wife because she gets very nervous. It saddens you greatly to see what has happened to your quality of life because of this disease. You were a very active man in the past (retired teacher). You feel anxious at times. When asked about whether you want your family present during a discussion about end-of-life issues, you state that you want to discuss it alone. You may say things like: My mind is sharp as a tack, but my body is giving out. My quality of life has really gone downhill. Why would I go to unnecessary lengths to prolong my suffering? I wouldn't want to live like that. I would hope someone would kill me if ever I got into a situation where there was no hope for recovery. Prompts are used to standardize the scenario and give all candidates an opportunity to address relevant issues. PROMPT 1: (when introduced to DNR discussion) Doctor, am I dying? PROMPT 2: (when asked about DNR order) Why won't you do CPR for me?

of 193

Station 8: Assessing Decision Making Capacity Issue Assessing Decision Making Capacity Presenting Situation A 77-year-old nursing home resident with Alzheimer’s disease has just had an episode of GI bleeding. She declines further work-up. The fellow will assess her decision making capacity. Activity Patient encounter Time Required 15 minutes This station was developed by Jorge Ruiz, MD


of 193

Station Number 8 Setting: Nursing home patient’s room. You are about to see Mrs. Sylvia Diaz, a 77-year-old Hispanic female who is a nursing home resident. Over the past few years she has become forgetful and occasionally confused. She was diagnosed with Alzheimer's dementia 1 year ago (recent MMSE 20/30). She is able to recognize relatives and nursing home staff. She is in essentially in good physical health and seems happy and content. However, her memory problems are getting worse. Yesterday, she passed some bright blood per rectum. She does not have hemorrhoids, and she is hemodynamically stable. Her only laboratory abnormality is a hemoglobin of 8 (previous hemoglobin was 12). She told the nurses at the long term care facility that she does not want to have any more tests. You are considering consulting GI for an endoscopy to see where the bleeding is coming from, followed by surgery if a cancer is found. Task: Please assess Mrs. Diaz’ capacity to consent for endoscopy. Thereafter, please return to the coordinator where you will provide written documentation of the clinical encounter. * * You may revise this text to reflect the needs and objectives of your specific case, but the time limit needs to stay at 15 minutes.


of 193


Checklist: Decision Making Capacity Station 8


Yes No

1. Sat down in order to be at eye level with me. Asked family members or others to leave.

2. Asked an open-ended question to elicit what I understand about my current health situation

3. Told me that he/she has concerns about my ability to make decisions

4. Asked me if it is okay to ask few questions to assess my ability to make my own decisions

5. Assessed ability to express a choice (Asked me whether you want the tests: YES or NO)

6. Assessed ability to understand relevant information (Asked me to repeat in my own words)

7. Assessed ability to appreciate the situation and consequences (Asked me what would happen to me if I do or do not have the test)

8. Assessed ability to reason with relevant information (Asked me WHY I made this decision)

9. Documented whether the patient has decision making capacity including the four domains Comments or Clarifications:


of 193



Excellent

Good

Fair

Inadequate

Poor

2 How would you rate the candidate's ability to assess decision making capacity?

Excellent

Good

Fair

Inadequate

Poor




of 193


Your name is Sylvia Diaz. You are 77 years old, and you live in a nursing home. Over the past few years you have become forgetful and occasionally confused. You have Alzheimer's dementia. You are able to recognize relatives and nursing home staff and are otherwise in good physical health. You seem happy and content. However, your memory problems are going to get worse. One day you pass some blood in your stool. You can choose not to work it up, or your doctor can arrange for you to undergo tests to see where the bleeding is coming from followed by surgery if a cancer is found. Your husband died 6 years ago. You do not have any children. Ability to express a choice You repeatedly say NO to the testing. Ability to understand relevant information You tell the doctor in your own words what the doctor told you about: The nature of your condition

I have some kind of problem in my bowel, a tumor or something. The recommended treatment (or diagnostic tests)

You want to put a tube in my butt (mouth). The possible benefits from the treatment

I don’t know. You tell me. The possible risks (or discomforts) of the treatment

You can puncture my bowel; you can kill me with that. The possible risks and benefits of alternative treatments

Just give me medicine, I don’t want you to mess with me, let me go to my room, whatever you have doc, fix me and let me go.

The possible risks and benefits of no treatment at all I don’t care if I die, I’m too old. I just want to go to my room and watch TV.

Your doctor told you of a chance that (Named risk) might occur with treatments. In your own words, how likely to do you think the occurrence of (Named risk) might be?

I guess it can happen, I don’t know. Why is your doctor giving you all this information?

Because I’m sick; I’m bleeding. What role does the doctor expect you to play in deciding whether you receive treatment?

I’m the boss. I want to make my own decisions. What will happen if you decide not to go along with your doctor's recommendation?

I can die but I am ready to die, or maybe it’ll go away. I’m just too old. Ability to appreciate the situation and consequences Tell me what you really believe is wrong with your health now.

I told you. I have been having blood in my stool. Do you believe that you need some kind of treatment?

Yeah, give me medicine. I do not want any more tests!


of 193

Station 8: Standardized Patient Script (continued) What is the treatment likely to do for you? Why do you think it will have that effect?

It will stop the bleeding. What do you believe will happen if you are not treated?

I’ll continue bleeding or maybe die. Why do you think your doctor has recommended (specific treatment) for you?

Because I’m sick. I’m bleeding! Ability to reason with relevant information Tell me how you reached the decision to accept (reject) the recommended treatment

What you mean? You’re talking to me about my bowels, and the bleeding may be coming from inside. I am just too old, and I do not want to mess around. I have been in the hospital before. I just do not want to bother anymore. I am answering your questions.

What were the factors that were important to you in reaching the decision? I just want to get better and go to my room. I just to want you to leave me alone. Doctor, I lived a long life; I am ready!

How did you balance those factors? What? Well, I’m old; I am really happy here. I have friends, and I like the nurses. I do not want to go anywhere.

Prompts are used to standardized the scenario and give all candidates an opportunity to address relevant issues. PROMPT 1: (when Dr. begins asking questions) Doctor, why are you asking me all these questions? PROMPT 2: (when asked about consent for endoscopy) Why do you want me do that?


of 193

Station 8: Helpful guidelines for scoring Questions the fellow should ask Ability to express a choice • Have you decided whether to go along with your doctor's suggestions for treatment? • Can you tell me what your decision is? Can be repeated at the end of the interview

to assess stability of choice. Ability to understand relevant information Please tell me in your own words what your doctor told you about: • The nature of your condition • The recommended treatment (or diagnostic tests) • The possible benefits from the treatment • The possible risks (or discomforts) of the treatment • The possible risks and benefits of alternative treatments • The possible risks and benefits of no treatment at all • Your doctor told you of a chance that (Named risk) might occur with treatments. In

your own words, how likely to do you think the occurrence of (Named risk) might be? • Why is your doctor giving you all this information? • What role does She expect you to play in deciding whether you receive treatment? • What will happen if you decide not to go along with your doctor's recommendation? Ability to appreciate the situation and consequences • Tell me what you really believe is wrong with your health now • Do you believe that you need some kind of treatment? • What is the treatment likely to do for you? Why do you think it will have that effect? • What do you believe will happen if you are not treated? • Why do you think your doctor has recommended (specific treatment) for you? Ability to reason with relevant information • Tell me how you reached the decision to accept (reject) the recommended treatment • Explain to me how you compared the treatment alternatives offered to you • What were the factors that were important to you in reaching the decision? • How did you balance those factors?

of 193

Station 9: Elder Abuse Issue Identifying potential elder abuse Presenting Situation The fellow has cared for a patient with multiple medical comorbidities for the past three years. He comes today to the clinic accompanied by his wife after missing his last two appointments. He was last seen eight months ago. Activity Patient encounter Time Required 15 minutes This station was developed by Osvaldo Rodriguez, MD Props Medication list – provided Laboratory report – provided Completed Zarit caregiver burden scale: 8/16 (high burden) – provided MMSE score 16/30 GDS score 9/15 Two-wheeled walker Sham Foley with bag filled with apple juice Reflex hammer Penlight Gowns Make-up


of 193

Station Number 9 Setting: Physician’s office Mr. Bucci comes to your office for a follow up visit accompanied by his wife. You are concerned because Mr. Bucci has missed two previous medical appointments even though he has been very compliant with his appointments and medical management in the past. It has been 8 months since you last saw him even though you usually see him every three months because of his multiple comorbidities. Vitals: Temperature: 98.4 Blood Pressure: Supine 160/94, Sitting 132/80 Unable to stand Heart rate: Supine 84, Sitting 98 Respirations: 20 Pain: 5/10 (Lower back and neck and shoulders) Task: Please evaluate and manage Mr. Bucci. You have 20 minutes to:

• complete a focused history and physical exam • discuss your findings and plan with your patient and caregiver • provide written documentation of your findings*

* You may revise this text to reflect the needs and objectives of your specific case, but the time limit needs to stay at 15 minutes.

of 193


Checklist: Elder Abuse Station 9


DURING THE ENCOUNTER Yes No A. History 1. Kept me as the primary focus of the interview throughout 2. Asked me about reason for missing recent medical appointments 3. Asked to interview me and my wife/caregiver separately 4. Asked me about change in functional status (ADLs, IADLs) 5. Asked me about recent behavioral disturbances (depression, wandering, psychosis,

personality changes) 6. Asked me about any changes in my living situation 7. Asked me if I have any safety concerns at home 8. Asked me about new physical symptoms (fatigue, increased pain, polyuria, polydipsia,

fever, chills, sleep disturbance, decreased appetite) 9. Asked me about recent falls 10. Obtained a current medication list including herbals/OTCs, alcohol 11. Asked me/wife if there are any weapons in the house 12. Asked me/wife if the police has come to the house recently 13. Asked me/wife if there have been threats or instances of physical abuse 14. Asked me/wife if there are any new financial concerns B. Examination 1. Initiated MMSE or CDT/Depression screen 2. Initiated a complete skin exam looking for signs of abuse (bruises in different stages of

healing or in unusual places, cuts/abrasions/cigarette burns, etc) 3. Initiated a complete head and neck exam looking for signs of abuse (trauma, bruises) 4. Initiated a complete musculoskeletal exam looking for signs of abuse (head trauma, bone

deformities, etc) C. Communication with patient and family 1. Described his/her concerns for my safety in view of findings from history and physical 2. Elucidated my preferences/goals regarding my present living situation 3. Addressed caregiver burden WRITTEN PORTION A. Work-up 1. Asked to do labs: CBC, CMP, prealbumin, Ca, TSH, B12, folate, A1c, digoxin levels, lipid panel (give card with previous and recent labs) 2. Determined need for imaging of any body sites suspicious for traumatic injury 3. Determined need for referrals (SW, PT/OT for home safety check, proper authorities) B. Diagnosis 1. Identified possible elder abuse/neglect/exploitation by nephew 2. Diagnosed depression with anxiety component 3. Diagnosed high caregiver burden with high potential for elder abuse/neglect C. Plan 1. Initiated medications for depression 2. Referred to social work/PT/OT for evaluation of home situation 3. Addressed need for continued monitoring of patient safety 4. Addressed need for continued monitoring of caregiver burden 5. Addressed need to report case to proper authorities for further investigation (Florida DCF)


of 193


Excellent

Good

Fair

Inadequate

Poor

2 How would you rate the candidate's ability to evaluate patients with elder abuse & neglect?

Excellent

Good

Fair

Inadequate

Poor



of 193

Station 9: Standardized Patient Script Information about the current situation You are Mr. Mario Bucci. You live with your wife of 60 years in a one story house you and your wife own. You have multiple medical problems including Alzheimer’s dementia, high blood pressure, diabetes, previous stroke, urinary retention due to prostate problems, emphysema, arthritis and angina (coronary artery disease). Because of your Alzheimer’s dementia, you are aware that you have some pain and a “sugar” problem, but you don’t remember anything else. You are very confused now with the situation at home since your nephew came to live with you 10 months ago. Recently you had a fall. You are not sleeping or eating well. You are afraid something bad is going to happen to you or your wife. Your wife has told you that you may lose your home.

Past Medical History Alzheimer’s dementia Stroke History of depression Hypertension Diabetes Urinary retention Chronic bronchitis Arthritis Angina History of falls Past Surgical History none Allergies none Family History Your mother had sugar problems Social History Married x 60 years High school education Worked as a cop until retirement

Medications atenolol 25mg daily lisinopril 10 mg daily aspirin 325 mg daily digoxin 0.125 mg daily isosorbide mononitrate 30 mg daily acetaminophen as needed (over the counter) terazosin 2 mg at bedtime vitamin E (over the counter) donepezil 10 mg daily insulin NPH 20 units daily insulin regular sliding scale ascorbic acid 500 mg daily docusate 250 mg at bedtime Functional status Reading glasses Mild hearing loss Foley catheter (that you’d like removed) Feed yourself Need help with all other ADLs (bathing, dressing, toileting, transferring in and out of bed) Wife does all IADLs (using the telephone, grocery shopping, driving, cooking, cleaning the house, doing laundry, managing medications, and handling your finances)

of 193

Station 9: Standardized patient script (continued) You will answer all questions asked by the fellow. Try to be brief in your responses. If an unfamiliar term or phase is used (like disorganized thinking, aphasia, agnosia, apraxia, or executive function), just say, “I don’t know.” Possible questions the fellow may ask and suggested responses: General introductory questions If asked why you missed your last 2 appointments:

I did not know I had any medical appointments! Oh! I think my wife has been having problems with the car. (Shake your head)

If you are asked about any recent medical problems I have been having more back and leg pain lately.

If you are asked if you are having concerns for your health I wish I could walk more; I want this tube out (point towards your urinary catheter).

Abuse If the fellow asks to talk to you alone

I guess it’s okay (looking anxiously at your wife). What do you think, honey? If you are asked about any verbal or physical abuse

My nephew screams at me or my wife at times. If you are asked if you have any weapons in the house

I don’t think so, but I know a lot about weapons. I used to be a cop. Mood and behavior You may be asked about depression, which you DO have:

• Mood – I worry a lot lately about my wife. • Lack of interest in doing things – I don’t feel like doing much lately. • Sleep – My nephew does not let me sleep. He brings friends to the house and

they make a lot of noise at times. • Guilt – My wife says I have been nasty to her lately. • Energy – I don’t have much energy lately. • Concentration – I don’t know. • Appetite – I don’t have much of an appetite. • Weight loss – I don’t know. • Agitation, restlessness or slowness in moving about – Deny it (but look anxious,

look into space. • Suicidal thoughts – No, that’s against my religion.

If you are asked about feeling lonely No, my wife keeps me company.


of 193

Station 9: Standardized patient script (continued) If you are asked about feeling anxious, say

What do you mean? (with an anxious look) If you are asked about hallucinations, psychosis, or paranoid delusions

No, I don’t think so. If you are asked about disruptive behavior, say

What do you mean by that? I don’t think so.

Safety If you are asked about getting lost on familiar routes while driving

I don’t drive anymore. If you are asked about any concerns for your personal safety at home

I’m worried that something is going to happen to my wife. If you are asked about any changes in your living situation

Yes, my nephew and his girlfriend moved in to our house a while back. If you are asked about dangerous events at home

My nephew screams at my wife or at me sometimes; a cop who is a good friend of mine came the other night to check on us.

If the fellow tells you abruptly that he is concerned about your safety I worry about my wife!

Functional Status If you are asked about your ability to bathe, dress, use the toilet, transfer, remain continent, or feed (ADLs)

I need help with everything, but I can eat by myself. • Bathing – I need help. • Dressing – I need help. • Using the toilet or grooming – I need help. • Feeding yourself – I eat pretty well. • Moving around the house – I use a walker, my wife helps me. • Continence or making it to the bathroom on time – I need help.

If you are asked about your ability to use the phone, shop, drive, cook, clean, do laundry, manage medications, or handling finances (IADLs)

My wife does all that. I think my nephew has been helping with the bills lately. • Using the telephone – I have problems hearing. • Grocery shopping – I don’t get out of the house. • Driving – My wife drives for me, but I think she lost her car. • Cooking – My wife is a good cook. • Cleaning the house or doing laundry – I can’t do that. • Managing medications – My wife gives them to me. • Handling your finances – My wife takes care of that.


of 193

Station 9: Standardized patient script (continued) If you are asked about a history of falling

Not that I remember. I’m very careful. Medical history and medications If you are asked about physical symptoms (such as chest pain, cough, fever, shortness of breath, palpitations, increased thirst, urinary frequency, etc.)

All I have is worsening back and leg pain. If you are asked if you have medical conditions or problems

I’m not sure what you mean and look to your wife (she will say “like what” to prompt the fellow to ask about some specific medical conditions on the checklist.)

If you are asked to describe your memory problem I don’t think I have a memory problem!

If you are asked about medications I take a few pills, and look to your wife for details. You do not take any medications other than the ones prescribed to you.

Family history and social circumstances If you are asked about illnesses in the family

I can’t remember right now. If you are asked about your living arrangements

I have lived in my house with my wife for many years, I wish I could stay there until I die.

If you are asked about • Career: I used to be a cop. • Marital status: Married for many years. • Children/other family: My nephew moved in to live with us recently. • Leisure activities: I like to watch TV but my eyes are no good. • Religion: I am Catholic, but I can’t go to church anymore.

Physical examination If the fellow initiates a physical exam (says, “I’d like to examine you now”)

Skin: A couple bruises over forearm area near wrists (point to them) HEENT: mild abrasion over scalp (you don’t remember what happened) Neck: Some stiffness, difficult to move Chest: Clear Heart: Normal Abdomen: Soft, non tender, normal bowel sounds, voluntary guarding Back: No spine tenderness GU: Foley in place, draining clear urine Rectal: REFUSE IT


of 193

Station 9: Standardized patient script (continued)

Extremities: Trace edema, no cyanosis or clubbing Musculoskeletal: pain on palpation over right shoulder Neurological: Alert, oriented to name and place (doctor’s office) only Gait: sit up with difficulty, you can’t get out of the chair without help Motor: Decreased strength of your muscles in arms and legs (worse on the right) Sensory: The fellow may use a pointing device to poke your skin, you feel decreased sensation in your legs Cranial nerves: You may be asked to follow the fellows’ finger or do some maneuvers with your head and neck. You have normal vision and decreased hearing. You have some difficulty moving your head and right arm due to pain. Cerebellar signs: you may be asked to perform alternating movements with your hands and fingers ( you have some difficulty doing this, remember you had a stroke and your right side is weak)

If you are asked to draw a clock or the fellow starts administering the Mini-mental state examination (MMSE)

Your wife will hand the fellow a piece of paper with your results saying the nurse had you do this while you were waiting.


of 193

Station 9: Standardized Caregiver Script

You are bringing your 85-year-old husband to a follow-up clinic appointment. He has many medical problems. He has Alzheimer’s dementia and for the past 3 years you have been doing everything for him because he can barely get around. He had a stroke, is weak on his right side, and has a urinary bag; you have missed the last two appointments because you have been having transportation problems ever since your husband’s nephew, who moved into your home 10 months ago, took your car and crashed it. You finally got your car back. You have a high amount of stress at home because your husband’s nephew has been verbally abusing you and your husband and has been continuously “strong arming” you to go to the bank and withdraw money which you suspect he is using to buy drugs. Even though you have a good source of income, your funds have been depleted by your husband’s nephew. You are 3 months behind on your mortgage and the bank has sent a letter initiating foreclosure. You are also behind on several other scheduled payments. You are concerned you are going to lose the house because of non-payment or if the police come and find drugs in the house. You have also noticed that your husband is more anxious lately and is becoming more verbally abusive with you. You are having increasing difficulty remembering to give him his many medications on time and checking his sugars regularly. You feel overwhelmed and can’t think straight. You called a cop who is a friend of your husband once. He came to your house and told you that you need to have your nephew moved out of the house. You feel bad for him and wonder what would happen to him without your help. One time at night you almost called the police because you heard noises in the house and found your nephew with some friends of his in the house. This situation has happened several times. Please review the standardized patient script for a summary of your husband’s medical history. Your husband will try answering all questions asked by the fellow, but you will often add more details because he will forget or keep looking to you for help. Allow the fellow time to address your husband first, and only answer questions that are directed specifically towards you by the fellow or your husband. However, you should use nonverbal behaviors such as shaking your head or rolling your eyes to suggest you might have a different opinion when your husband answers something you believe is incomplete or incorrect. If the fellow asks to talk to you or your husband separately about some issues, you will agree (You want to make the fellow aware of the home situation with your husband’s nephew, but you don’t want to discuss it in front of your husband because you don’t want to worry him more.) If an unfamiliar term or phase is used (like disorganized thinking, aphasia, agnosia, apraxia, or executive function), just say “I’m not sure what you mean.”


of 193

Station 9: Standardized Caregiver Script (continued) General Prompts If about half-way through the interview the fellow has not addressed certain areas and seems a bit off track, you can give some general prompts to help him/her remember to ask about these areas. Here are a few examples, but you may need to ad lib. Prompt for functional status

I am really worried about our living situation and being able to take care of my husband at this point.

Prompt for medical history or medications What could be causing my husband to be more withdrawn and sleepy lately? He is not eating much.

If the fellow has not asked why you missed the last two appointments Apologize to him saying; I’m sorry that I missed the last appointments but I have had a lot of difficulty bringing my husband here.

If the fellow does not ask to talk to you in private Ask him/her to speak to you alone about other concerns you have.

If the fellow gets side tracked or spends too much time on one issue, indicate you are not concerned about that and attempt to redirect him/her. If there are only a few minutes remaining and the fellow has not begun a discussion about what he/she thinks is going on and what work-up or treatment is recommended, you should prompt him/her to do this. Here are a few examples of what you might say:

• What do you think I should do now? • Is there any help available for me now? • What’s wrong with my husband? • Doctor, I am worried! • My husband is losing weight; I’m afraid something may be wrong.

Possible questions the fellow may ask and suggested responses: Memory If you are asked when the memory problem started

I first noticed it about 8 years ago. If you are asked to be more specific about the memory problem

He still recognizes his family but cannot be left alone. He needs help with everything, and I’m afraid if I leave him alone, something bad will happen to him!

If the fellow tries to distinguish between recent versus remote memory problems He still remembers things from when he used to work as a policeman but has trouble remembering stuff I told him 10 minutes ago.


of 193

Station 9: Standardized Caregiver Script (continued) If you are asked if your husband has difficulty recognizing familiar persons, places, or things

Sometimes it seems like he does not recognize me! If asked about executive function (judgment, insight, inability to do complex tasks, changes in personality)

He seems more withdrawn lately. He seems to have a short fuse with me. If you are asked if your husband has problems paying attention or if his symptoms fluctuate

Yes, I often have trouble getting his attention. Many times he starts eating and seems to forget what he is doing.

Mood and behavior Your husband may be asked questions about depression. You should confirm his responses (he has trouble sleeping, is eating less, and complaining of more pain). If you are asked if he has hallucinations, psychosis, or paranoid delusions

No, not that I’ve noticed. If you are asked about disruptive behavior or agitation

He seems more agitated when the nephew is around! Safety If you are asked about safety at home

I’m more concerned for my husband’s safety lately. If you are asked about wandering (walking around aimlessly)

No, he can’t get out of bed without help. If you are asked about dangerous events at home

• One time I came to the house after I went shopping and overheard my husband’s nephew screaming at him and asking him if he had any money.

• I was very concerned one night when I heard noises in the house. I found my husband’s nephew with 4 or 5 strangers inside my house. They had loud music and were laughing a lot.

• My husband’s nephew took my car and crashed it. That’s why I could not come to the last 2 appointments.

Functional status If you are asked about changes in your husband’s abilities to bathe, dress, use the toilet, transfer, remain continent, or feed (ADLs)

He needs help with all of that and lately he has been having problems feeding himself.

If asked about your husband’s ability to use the phone, shop, drive, cook, clean, do laundry, manage medications, or handling finances (IADLs)

• Using the telephone – He is hard of hearing. • Grocery shopping – I do that.


of 193

Station 9: Standardized Caregiver Script (continued)

• Driving – He can’t drive. • Cooking – I do that; my husband does not go in the kitchen. • Cleaning the house or doing laundry – I could use some help with that! • Managing medications – I put the pills in one of those weekly pillboxes, but I

have been more confused lately. • Handling finances – I pay all the bills but I have been having problems lately.

If asked about a history of falls Oh, yeah, I forgot to mention that. He fell a month ago when getting out of bed. He bumped his head, but it is healing well.

Medical history and medications If your husband is asked about physical symptoms (such as chest pain, cough, fever, shortness of breath, etc.)

He just seems more tired and reports more pain. If your husband is asked about any prior medical conditions

• First say, “Like what?” (this open-ended response will prompt fellows to ask about some specific medical conditions below)

• Then offer that he has high blood pressure, diabetes, arthritis, heart problems, a stroke 5 years ago, memory problems, and problems urinating and has a urinary catheter.

• He has been depressed in the past, especially after the stroke. You are concerned because you think he might be depressed again.

If asked about your husband’s medications, say Yes, he takes many medications. (Hand hand the list to the fellow.)

If asked about recent dose adjustments or new medications No, there haven’t been any changes.

Family history and social circumstances If you are asked about illnesses in the family

His mother had diabetes. If asked about your husband’s smoking, alcohol, and drug use patterns

My husband used to smoke for about 20 years. He quit about 30 years ago; he does not drink and never used drugs.

If asked about any changes in your living situation My husband’s nephew recently moved in the house.

Regarding your husband’s career, marital status, leisure activities, and religion Simply support his answers.

Physical examination If the fellow asks to examine your husband in private

Don’t refuse, say go ahead and offer to leave the room.


of 193

Station 9: Standardized Caregiver Script (continued) If the fellow asks you about the bruises on your husband’s wrists

I don’t know what happened. I first noticed them when I came back from shopping one day (his nephew was alone with him). When you asked your husband, he said he did not remember what happened, but he looked scared.

If the fellow asks you about the abrasion on your husband’s head Oh, my husband says he scratched his head by accident.

Caregiver burden If the fellow asks if you are overwhelmed caring for your husband Hand him/her the Zarit Burden Interview, which the nurse had you fill out while you were waiting. Possible responses:

• It’s really hard for me. My husband is weaker and my nephew does not seem to be of much help!

• I’m very concerned about our financial situation. I think my husband is noticing too.

• He and I would like to stay at home, but I don’t think this is going to be possible anymore.

• He is taking so many medications; it is all getting very confusing for me. • I have not been feeling well lately. • I’m very stressed, I don’t think I can go for much longer like this.

The fellow’s assessment and plan If the fellow tells you abruptly that he suspects elder abuse/neglect/financial exploitation

I’m very concerned too, but I feel sorry for my nephew. I hope nothing happens to my husband or me. Is there anything you can do to help me?

Likewise, if the fellow says your husband has depression ask Do you think he should be taking medications for his depression again?

If the fellow tells you that he might have to send somebody to check the home situation Don’t refuse; say you are willing to cooperate with whatever is needed to help improve the situation.


of 193

MARIO BUCCI Medication List atenolol 25mg daily lisinopril 10 mg daily aspirin 325 mg daily digoxin 0.125 mg daily isosorbide mononitrate 30 mg daily acetaminophen as needed (over the counter) terazosin 2 mg at bedtime vitamin E (over the counter) donepezil 10 mg daily insulin NPH 20 units daily insulin regular sliding scale ascorbic acid 500 mg daily docusate 250 mg at bedtime


of 193

MARIO BUCCI Laboratory Report Hgb A1c 8.3% (Previous 7.2%) Digoxin level <0.3 mg/mL (Previous 0.82 mg/mL) Fasting Glucose 185 mg/dL (Previous 102 mg/dL) BUN 26 mg/dL Creatinine 1.1 mg/dL Sodium 130 mmol/L (Prev 135 mmol/L) Potassium 5.0 mmol/L (Prev 4.8 mmol/L) Total Protein 6.4 g/dL (Previous 7.0 g/dl) Albumin 3.3 g/dL (Previous 3.7 g/dl) Cholesterol 203 mg/dL HDL 32 mg/dL LDL 140 mg/dL WBC 6.7 Hemoglobin 12.4 (Previous 13.0) Hematocrit 36.7% (Previous 38.6%) Urinalysis Presence of amorphous urates; neg nitrates,

neg leukokcyte esterase; pH 5.0 B12 600 (normal) Folate Normal RPR Negative TSH 2.8 (normal)

of 193

Zarit Burden Interview (screening version)

Patient’s Name: Mario Bucci Relationship to patient: Wife DO YOU FEEL . . . that because of the time you spend with your relative that you don’t have enough time for yourself?

3

stressed between caring for your relative and trying to meet other responsibilities (work/family)?

3

strained when you are around your relative?

1

uncertain about what to do about your relative?

1

TOTAL 8 All questions are answered as “never” (0), “rarely” (1), “sometimes” (2), “quite frequently” (3), or “nearly always” (4). The highest total possible score is 16. A score of 8 or more indicates high burden. From Bédard M, Molloy DW et al. The Zarit Burden Interview: A New Short Version and Screening Version. The Gerontologist 2001;41(5):652–57.

of 193

Station 10: Cognitive Impairment Issue Cognitive impairment Presenting Situation A patient is brought to clinic by her son for a new patient visit. She feels well, but her son is concerned about her memory. Activity Patient encounter Time Required 15 minutes This station was developed by Anita Bagri, MD Props Medication list – provided Laboratory report – provided MMSE score 19/30 GDS score 3/15 Tuning fork Reflex hammer Penlight Gowns


of 193

Station Number 10 Setting: Physician’s office Mrs. Norman is an 80-year-old brought to your clinic by her son for a new patient visit. She feels well, but her son is concerned about her memory. Vitals: Temperature: 97.2 Blood Pressure: Supine 150/90, Standing 145/85 Heart rate: Supine 68, Standing 68 Respirations: 14 Pain: 0/10 Task: Please evaluate Mrs. Norman’s memory problem. You have 15 minutes to:

• complete a focused history and physical exam • discuss your findings and plan with your patient and caregiver • provide written documentation of your assessment and plan *

* You may revise this text to reflect the needs and objectives of your specific case, but the time limit needs to stay at 15 minutes.


of 193


Checklist: Cognitive Impairment Station 10


DURING THE ENCOUNTER Yes No A. History 1. Kept me as the primary focus of the interview throughout 2. Assessed for onset/time course of symptoms (r/o delirium) 3. Asked me about memory loss, forgetfulness 4. Asked me about change in functional status (ADLs, IADLs) 5. Asked me about behavioral disturbance (depression, wandering, psychosis, personality

changes) 6. Addressed safety issues with me (driving, cooking) 7. Asked about my living situation (alone or with family) 8. Asked my past medical history (including HTN, CVA/TIA, DM, lipids, EtOH abuse) 9. Obtained a current medication list including herbals/OTCs, alcohol 10. Asked about any family history of dementia 11. Asked me about head trauma 12. Asked me about signs and symptoms of other acute conditions (infections, heart disease,

etc.) B. Examination 1. Initiated MMSE or CDT 2. Initiated a physical exam 3. Initiated a complete neurologic exam C. Communication with patient and family 1. Described to me the proposed work-up, likely diagnosis, and realistic impression of medication effectiveness in terms I understood 2. Elucidated my preferences/goals regarding my living situation 3. Addressed caregiver burden (referred son to support groups) WRITTEN PORTION A. Work-up 1. Ordered CBC, CMP, Ca, lipids, TSH, B12, folate 2. Determined need for imaging and justify decision 3. Determined need for neuropsychiatric testing, justify decision B. Diagnosis 1. Used DSM-IV criteria for Alzheimer dementia C. Plan 1. Initiated medications (AChE, NMDA) 2. Referred to social work for home services 3. Addressed need for continued monitoring of patient safety 4. Addressed need for continued monitoring of caregiver burden 5. Ordered educational materials about dementia Comments or Clarifications:


of 193


Excellent

Good

Fair

Inadequate

Poor

2 How would you rate the candidate's ability to evaluate cognitive impairment?

Excellent

Good

Fair

Inadequate

Poor




of 193

Station 10: Standardized Patient Script Information about the current situation You are Mrs. Josea Norman, an 80-year-old woman who lives alone since your husband died 3 years ago. Your son lives 30 minutes away and comes to visit you three times a week. He is concerned about you and tells the doctor he has noticed a change in you over the past 18 months; he feels it is a memory problem. However, you do not think anything is wrong. He has noticed that although your clothes are clean, your outfits don’t always match. The house, which you have always maintained well, has become cluttered. He has noticed unopened mail at your house and has started paying your bills for fear that you have not been taking care of your finances. He tells the doctor you have been asking the same questions over and over. Of most concern to him, he has seen you drive and become confused at intersections, although you have not had any accidents. Past Medical History High blood pressure Osteoporosis Arthritis Right wrist fracture after falling on wet floor 6 months ago Past Surgical History None Allergies None Medications atenolol 25mg daily calcium and vitamin D twice a day risedronate 35mg once a week acetaminophen as needed (over the counter) gingko biloba (over the counter – son purchased for you) vitamin E (over the counter – son purchased for you) Family History Mother had “senile dementia” Mother died of old age at 83

Social History: Married x 57 years Two children (daughter in California, son who accompanies you today) Son is divorced and takes care of his teenage daughter No tobacco Rare alcohol (on holidays only) College degree in education Sixth grade math teacher x 22 years Methodist Friendly neighbors but few friends Functional Status: Reading glasses No hearing problems No incontinence Independent with ADLs (bathing, dressing, toileting, transferring in and out of bed, and feeding) Independent with some IADLs (using the telephone, grocery shopping, driving, cooking, cleaning the house, doing laundry, managing medications) Son has started taking over your finances

of 193

Station 10: Standardized Patient Script (continued) You will answer all questions asked by the fellow; try to be brief in your responses. When the son adds more details, do not deny what he says, but minimize their importance and attribute them to “just being old.” You feel your son is over-reacting when he expresses concern. If an unfamiliar term or phase is used (like disorganized thinking, aphasia, agnosia, apraxia, or executive function), just say “I don’t know”. Memory If you are asked to describe your memory problem

My memory is fine. I mean everybody has some difficulty remembering things at my age.

If you are asked when the change in behavior started or if you think you are having any problems

I’m fine, my son worries too much. If you are asked if your memory problems come and go (fluctuate) or are better at times

I don’t know. If you are asked if you have been drowsy or lethargic lately

Well, I take a little nap once in a while. If you are asked if you are having problems paying attention

My son complains I don’t listen. If you are asked if you have trouble remembering names or finding words

I don’t think so. If you are asked if you have trouble recognizing familiar persons, places or things

I’m fine, just ask my son. If you are asked if you have difficulty doing complex tasks or planning for things

No. Mood and behavior You may be asked about depression, which you DO NOT have. If asked about these things, say:

• Mood – pretty good; I am a pretty happy person. • Lack of interest in doing things – not really, knitting and reading are just as

enjoyable as always but I don’t get out as much as before. • Sleep – no problems (if he asks more specifics, deny any problems and say you

sleep about 9-10 hours as you always have) • Guilt – never • Energy – I am not as active as I used to be, but I feel pretty good. • Concentration – no problems • Appetite – I eat fine. • Weight loss – not that I know of


of 193

Station 10: Standardized Patient Script (continued) • Agitation, restlessness or slowness in moving about – not that I have noticed • Suicidal thoughts – never

If you are asked about feeling lonely No, my son and I talk every day, and I have nice neighbors.

If you are asked about feeling anxious No, I feel fine.

If you are asked about hallucinations, psychosis, or paranoid delusions No, I’m not crazy.

If you are asked about disruptive behavior What do you mean by that? I’m a nice person.

Safety If you are asked about getting lost on familiar routes while driving

I don’t have any problems driving, although I don’t drive at night anymore If you are asked about any traffic violations or motor vehicle accidents

No, I haven’t had any accidents. I’m a safe driver. If you are asked about wandering (walking around aimlessly)

No, I don’t do that. If you are asked about dangerous events at home (leaving on the stove)

Not that I remember. Functional status If you are asked about your ability to bathe, dress, use the toilet, transfer, remain continent, or feed (ADLs)

• Bathing – I manage • Dressing – no problem • Using the toilet or grooming – no problem • Feeding yourself – I eat pretty well • Moving around the house – not as fast as I used to, but I manage • Continence or making it to the bathroom on time – no problem

If you are asked about your ability to use the phone, shop, drive, cook, clean, do laundry, manage medications, or handling finances (IADLs)

• Using the telephone – sure, I call my son • Grocery shopping – my son takes me • Driving – I don’t drive at night anymore, but otherwise I’m a safe driver • Cooking – I’m a pretty good cook • Cleaning the house or doing laundry – I do that myself • Managing medications – I do that • Handling your finances – lately my son has taken over that

If you are asked about a history of falling I fell six months ago and fractured my wrist.


of 193

Station 10: Standardized Patient Script (continued) Medical history and medications If you are asked about physical symptoms (such as chest pain, cough, fever, shortness of breath, etc.)

No. But I occasionally get aches and pains in my joints. My pain is relieved with acetaminophen.

If you are asked if you have medical conditions or problems I’m not sure what you mean and look to your son (he will say “like what” to prompt the fellow to ask about some specific medical conditions on the checklist.)

If you are asked about medications • I take a few pills, and look to your son for details. • Do not offer information about over the counter medications or herbals unless

specifically asked. Family history and social circumstances If you are asked about illnesses in the family

My mother had senile dementia. If you are asked about your living arrangements

I live alone, and I refuse to go anywhere else. That has been my home for over 30 years.

If you are asked about • Career: I am retired. (You used to teach 6th grade math.) • Marital status: My husband died 3 years ago of pneumonia. We were married for

57 years. I don’t date now. • Children: My daughter calls me once a week and I speak to my son daily. Even

though he lives 30 miles away and takes care of his teenage daughter alone, he comes to see me a few times a week.

• Leisure activities: I knit and read. • Religion: I am Methodist but rarely go to church.

Physical examination If the fellow initiates a physical exam (says, “I’d like to examine you now”)

Skin: Normal HEENT: Normal Neck: Supple, normal range of motion Chest: Clear Heart: Normal Abdomen: Soft, non tender, normal bowel sounds Back: No spine tenderness Rectal: REFUSE Extremities: No edema, cyanosis, clubbing Musculoskeletal: Normal


of 193

Station 10: Standardized Patient Script (continued)

Neurological: Alert, oriented to person (your name), place (doctor’s office). You make a mistake on the date. Gait: The fellow ask you to sit and then walk around: Get up and go (normal get-up-and-go tests, able to rise from chair, normal balance on standing, able to turn around) Motor: Normal strength of your muscles in arms and legs. Sensory: The fellow may use a pointing device to poke you skin, you feel normally the pressure or mild pain. Cranial nerves: You may be asked to follow the fellows’ finger or do some maneuvers with your head and neck. Check your hearing and vision. You do them all normally. Cerebellar signs: you may be asked to perform alternating movements with your hands and fingers or stand up with your eyes open and closed.

If you are asked to draw a clock or the fellow starts administering the Mini-mental state examination (see sheet) MMSE

Your son will hand the fellow a piece of paper with your results saying the nurse had you do this while you were waiting.

Fellow’s explanation of his/her assessment and plan If the fellow tells you abruptly that you have dementia or Alzheimer’s disease

Oh, I don’t have that. Doctor, you are wrong!


of 193

Station 10: Standardized Caregiver Script You are bringing your 80-year-old mother, Mrs. Josea Norman, to the doctor because you are worried about her memory. Since your father died 3 years ago, she has been living alone. You are divorced and live about 30 miles away with your teenage daughter. You have a sister, but she lives in California and is not involved in your mother’s healthcare. You are becoming increasingly concerned and overwhelmed caring for her. You have noticed a change in your mother over the past year. She asks the same questions over and over. Although her clothes are clean, her outfits don’t always match. The house, which was always maintained well, has become cluttered. You started paying her bills after noticing unopened mail at her house for fear that she has not been taking care of her finances. Of most concern to you is her driving; your mother sometimes seems confused at intersections and has gotten lost once although she has not had any accidents but a lot of near misses. In general, you are worried about her ability to safely continue living alone. Please review the standardized patient script for a summary of your mother’s medical history. Your mother will answer all questions asked by the fellow, but you will often add more details because she will minimize or downplay her symptoms. Allow the fellow time to address your mother first, and only answer questions that are directed specifically towards you by the fellow or your mother. However, you should use nonverbal behaviors such as shaking your head or rolling your eyes to suggest you might have a different opinion when your mother answers something you believe is incomplete or incorrect. If an unfamiliar term or phase is used (like disorganized thinking, aphasia, agnosia, apraxia, or executive function), just say “I’m not sure what you mean”. General Prompts If about half way through the interview the fellow has not addressed certain areas and seems a bit off track, you can give some general prompts to help him/her remember to ask about these areas. Here are a few examples, but you may need to ad lib.

• Prompt for functional status – I am really worried about her living alone and being able to take care of herself. Do you think she is safe?

• Prompt for medical history or medications – What could be causing her memory problem?

If the fellow gets side tracked or spends too much time on one issue, indicate you are not concerned about that and attempt to redirect him/her.


of 193

Station 10: Standardized Caregiver Script (continued) If there are only a few minutes remaining and the fellow has not begun a discussion about what he/she thinks is going on and what work-up or treatment is recommended, you should prompt him/her to do this. Here are a few examples of what you might say:

• What do you think is going on? • What could be causing her memory problems? • What should we do next? • Doctor, I am worried!

Possible questions the fellow may ask and suggested responses: Memory If you are asked if your mom has memory problems

This morning she did not remember that we had this appointment even though we talked about it on the phone yesterday.

If you are asked when the memory problem started I first noticed it about a year ago.

If you are asked to be more specific about the memory problems She frequently misplaces things and asks the same questions over and over.

If the fellow tries to distinguish between recent versus remote memory problems She still remembers things from when I was little but has trouble remembering stuff I told her 10 minutes ago.

If you are asked if your mother has problems naming or wording finding Not that I know o .

If you are asked if your mother has difficulty recognizing familiar persons, places, or things

A couple weeks ago, I took my son to see mom, and she didn’t recognize her, which was really upsetting.

If asked about executive functioning (judgment, insight, inability to do complex tasks, changes in personality), here are some responses to choose from:

• The house has become more cluttered than usual with piles of newspapers everywhere.

• She doesn’t seem to think that there is a problem with her memory or functioning. If you are asked if your parent has problems paying attention or if her symptoms fluctuate

Not really, but I sometimes feel like she’s not listening to me. Mood and behavior Your mother may be asked questions about depression. You should deny any mood disorders. Her responses are reliable and should be supported by you. When she is asked about lack of interest in activities, you may add

She used to go out to play bridge every week but stopped about 6 months ago. I don’t think it is because she lost interest, I think she couldn’t keep up anymore.


of 193

Station 10: Standardized Caregiver Script (continued) If you are asked if she has hallucinations, psychosis, or paranoid delusions

No, not that I’ve noticed. If you are asked about disruptive behavior or agitation

In the waiting room, she became a bit agitated by the TV and some children playing loudly.

Safety If you are asked about her driving

Even though she hasn’t had any accidents, I feel like she gets confused at intersections. And I got really worried that time she got lost coming home from the grocery store.

If you are asked about wandering (walking around aimlessly) No, she doesn’t do that.

If you are asked about dangerous events at home (leaving on the stove) Remember that time you left the stove on? Thankfully she didn’t start a fire or anything like that.

Functional Status If you are asked about changes in your mother’s abilities to bathe, dress, use the toilet, transfer, remain continent, or feed (ADLs)

She doesn’t have any problems that I am aware of. (Express some concern about her ability to take care of herself and mention that you are worried because you cannot always be there.)

If asked about your mother’s ability to use the phone, shop, drive, cook, clean, do laundry, manage medications, or handling finances (IADLs)

• Using the telephone – we talk everyday • Grocery shopping – we go together • Driving – I have tried to limit her driving but she insists on continuing • Cooking – I bring over frozen food so she only has to reheat things in the

microwave • Cleaning the house or doing laundry – Mom can do some things, but last month I

hired a maid • Managing medications – I put the pills in one of those weekly pillboxes • Handling your finances – I pay all the bills

If asked about a history of falls Oh, yeah, I forgot to mention that. She fell 6 months ago and broke her wrist.

Medical history and medications If she is asked about physical symptoms (such as chest pain, cough, fever, shortness of breath, etc.)

Not that I know of.


of 193

Station 10: Standardized Caregiver Script (continued) If your mother is asked about any prior medical conditions

• First say, “Like what?” (this open-ended response will prompt fellows to ask about some specific medical conditions below)

• Then offer that she has high blood pressure and arthritis. • She does not have a history of depression, alcohol abuse, smoking, or dementia.

If asked about your mother’s medications • Yes, she takes hydrochlorothiazide, calcium with vitamin D, and risedronate. • Do not offer vitamin E, gingko biloba, or acetaminophen unless specifically

asked. If asked about recent dose adjustments or new medications

No, there haven’t been any changes. Family history and social circumstances If you are asked about illnesses in the family

• Nothing that I know about. • Do not offer that your maternal grandmother had “senile dementia” unless

specifically asked. Regarding your mother’s career, marital status, leisure activities, and religious affiliation, her responses are reliable. Simply support her answers. Physical examination If the fellow asks your mother to draw a clock or starts administering the MMSE

The nurse asked her to do this while we were waiting, and here is what she did. (Hand the fellow a piece of paper with the results.)

If the fellow initiates a physical exam (says to your mother, “I’d like to examine you now”)

That’s fine, go ahead. (You help your mother get to the exam table.) Caregiver burden If the fellow asks if you are overwhelmed caring for your mother

• It’s really hard for me. Since my divorce, I take care of my teenage daughter alone, and there’s no one else nearby to help with mom.

• We don’t even live nearby, which makes things harder. My sister is of no help at all…she just tells me to put her in a nursing home.

• She really wants to stay at home, and I’d like that for her as long as we can make sure she is safe.

• I am so worried about her and would blame myself if anything happened to her. • I’m doing the best I can, but I wonder if it is enough.


of 193

Station 10: Standardized Caregiver Script (continued) Fellow’s explanation of his/her assessment and plan If the fellow tells you abruptly that your mom has Alzheimer’s disease, react very shocked and emotional.

Oh my gosh – Alzheimer’s – that’s awful! Likewise, if the fellow says your mother has dementia but has not sufficiently addressed the criteria, ask

What makes you think she has dementia (or Alzheimer’s)?


of 193

JOSEA NORMAN Medication List atenolol 25mg daily calcium and vitamin D supplementation twice a day risedronate 35mg once a week acetaminophen as needed (over the counter) gingko biloba (over the counter) vitamin E (over the counter)


of 193

JOSEA NORMAN Laboratory Report Fasting Glucose 110 mg/dL BUN 18 mg/dL Creatinine 1.0 mg/dL Potassium 4.0 mmol/L (Prev 4.8 mmol/L) Sodium 140 mmol/L (Prev 4.8 mmol/L) Total Protein 6.7 g/dL Albumin 4 g/dL Cholesterol 160 mg/dL HDL 32 mg/dL LDL 110 mg/dL WBC 5.0 Hemoglobin 13.0 Hematocrit 39% B12 500 (normal) Folate Normal RPR Negative TSH 3.0 (normal)

of 193

Station 11: Falls Issue Assessing and managing patients with falls Presenting Situation A patient who fell at home three days ago comes to clinic for an evaluation. Activity Computer-based patient management problems (Clinical vignettes) Time Required 20 minutes This station was developed by Marcos Milanez, MD Jorge Ruiz, MD


of 193

SCREEN 1 INSTRUCTIONS This clinical vignette takes approximately 20 minutes to complete. It is separated into parts. Each screen presents clinical material followed by questions you must answer. You may not backtrack between screens. As soon as you complete this vignette, you may go ahead to the next clinical case. SCREEN 2 Brief Case Introduction: Include here name, age, gender, setting, chief complaint, and a few associated symptoms or signs (do not reveal too much, just enough so the fellows can think to probe the patient/caregiver further). PLEASE CONTINUE READING THE VIGNETTE BELOW AND ANSWER THE QUESTIONS THAT FOLLOW.

Brief Case Introduction: Mr. Jason Rogers is a 75-year-old male who comes to your office for evaluation following a fall at home three days ago.

Questions: Choose the appropriate range of questions in your opinion. Remember, these are the most important questions. PLEASE READ ALL THREE QUESTIONS, THEN ANSWER UNDER THE MOST SUITABLE HEADING BELOW. DO NOT MOVE AHEAD UNTIL YOU HAVE ENTERED YOUR ANSWERS. Question: History of Present Illness What are the 7 (Range 5-7) to 12 (Range 8-12) most important questions you want to ask this patient about his/her symptoms? Question: Past Medical History What are the 3 (Range 3-5) to 6 (Range 6-9) most important questions you want to know about his/her past medical history? Question: Social-Family History What are the 3 (Range 3-5) to 6 (Range 6-9) most important questions you want to know about him/her as a person (his social history and other relevant issues)? SCREEN 3 History: In this portion of the vignette, you have to answer the previous three questions using a narrative format. You can add additional history if you wish. PLEASE CONTINUE READING THE VIGNETTE AND ANSWER THE QUESTION BELOW. DO NOT MOVE AHEAD UNTIL YOU HAVE ENTERED YOUR ANSWERS.


of 193

History: Mr. Rogers fell in his bedroom at night around 10 pm. He felt dizzy and lightheaded one hour after dinner. He stumbled on the wall and fell forward on his right knee. He has fallen several times before. Throw rugs are present throughout the trailer where he lives with his daughter. She was not home at the time of the fall. Mr. Rogers reports weakness and some nausea at the time he fell. He now describes pain and swelling of his right knee and wrist. He is very afraid of falling again. Past medical history: Congestive heart failure (NYHA stage III), hypertension (longstanding), osteoarthritis, and benign prostatic hypertrophy (BPH). No advance directives. Past Surgical History: transurethral resection of the prostate (TURP) and inguinal hernia repair Family Medical History: Parents died of “old age” Current Medications: acetaminophen 650 mg four times a day as needed for pain furosemide 40 mg twice a day for hypertension and congestive heart failure (increased 3 days ago; previously 40 mg in the morning) fosinopril 40 mg every morning for hypertension and congestive heart failure metoprolol 25 mg twice a day for hypertension and congestive heart failure terazosin 2 mg at bedtime for hypertension and BPH Social History: He lives with daughter in a trailer home. He completed high school and is a lower-middle class retired construction worker. He and his wife divorced 3 years ago. He enjoys watching TV. He used to smoke but quit 10 years ago. He drinks several beers each night. He drinks one cup of coffee every day. Review of Systems: He had been sleeping well until his dose of furosemide was increased. He has urinary urgency and nocturia and goes to the bathroom at least three times per night. He has shortness of breath on exertion at one block. He has right shoulder pain and denies swelling. He reports sadness, lack of enjoyment of hobbies and usual activities, low energy levels, and difficulty concentrating. Question: Physical Examination What are the 4 (Range 3-5) to 6 (Range 6-9) most important elements of the physical examination that need to be performed on this patient? (Please be very specific: for example, do not say you would “examine the knee”, but say what you would look for when you examined the knee, for example: “examine the knee for redness, swelling, point tenderness”).


of 193

SCREEN 4 Physical Examination: In this portion of the vignette, you present the physical findings. Be certain to include those that the fellow should have requested. Remember, these are the most important elements of the physical examination and should be presented in a narrative format. PLEASE CONTINUE READING THE VIGNETTE AND ANSWER THE QUESTION BELOW. DO NOT MOVE AHEAD UNTIL YOU HAVE ENTERED YOUR ANSWERS.

Physical Examination: Temperature: 97.5 F, Blood Pressure: supine 170/100 mm Hg; standing 145/90 mmHg, Heart rate (bpm): supine 58; standing 62, Respirations: 18/min and Pain: 4/10. Skin: normal. HEENT: diminished vision, early bilateral cataracts. Ears: normal, no cerumen noted. Chest: Clear to auscultation. Heart: RRR, Normal S1-S2, no gallops or murmurs. Abdomen: soft, non tender, normal bowel sounds. Rectum: small amount of soft stool, guaiac negative. Extremities: no edema, cyanosis, or clubbing. Musculoskeletal: knee pain elicited during flexion, mild swelling, bruises, lacerations, scrapes. Neurological: alert, oriented times three. Abnormal timed up and go test, with difficulty rising from chair and loss of balance on standing, uses a cane. MMSE (28/30), GDS (7/15). Motor: Lower extremities 3/5 symmetric.

Question: Diagnostic Work-up At this point, what consults, laboratory tests, or imaging studies would you order? SCREEN 5 Diagnostic Testing: In this portion of the vignette, you present the diagnostic test findings. Be certain to include those findings that the fellow should have requested. Remember this is a narrative format. PLEASE CONTINUE READING THE VIGNETTE AND ANSWER THE QUESTIONS BELOW. DO NOT MOVE AHEAD UNTIL YOU HAVE ENTERED YOUR ANSWERS.

Diagnostic Testing: CBC within normal limits except of MCV 105. Sodium 130, potassium 3.2, glucose 140, other electrolytes are normal. Alkaline phosphatase and GGT are elevated. UA shows 100 WBC/hpf, few bacteria. Knee and wrist X rays reveal no fracture or dislocation. EKG is normal sinus rhythm, occasional PVCs, no ST-T changes. Head CT without contrast is negative.

Questions: Assessment and Plan At this point, what is your diagnosis? Please be specific about the etiology. Are there other diagnoses? And what would your plan be, including your recommendations to the patient? Please be specific, and USE THE GERIATRICS FOUR DOMAINS.


of 193

PMP SCORING SHEET

Checklist: Falls Station 11

Please write each item in the history, physical exam, diagnostic testing, diagnosis and treatment in the space provided. HISTORY Done Not Done 1. History of falls 2. Urgency 3. Frequency 4. Nocturia 5. Uneven floor surface 6. Footwear 7. Lighting 8. Eyeglasses 9. Injuries 10. Lightheadedness 11. Vertigo 12. Disequilibrium 13. Alcohol intake 14. Location of the fall 15. Fear of falling 16. Throw rugs 17. Seizures/abnormal movements 18. Syncope 19. Chest pain, dyspnea 20. Medications 21. Memory problems 22. Mood 23. Clutter 24. Pain PHYSICAL EXAM Done Not Done 1. General assessment of performance status, physical distress and mood 2. Vital signs 3. Orthostatics 4. Cardiovascular 5. Respiratory 6. Musculoskeletal 7. Skin: ecchymosis 8. Rectal 9. Neurological 10. Gait and balance 11. MMSE 12. GDS


of 193

DIAGNOSTIC TESTING Done Not Done 1. CBC 2. BMP 3. Liver function tests 4. X rays Knee 5. X rays wrist 6. Head CT 7. EKG 8. UA DIAGNOSIS Done Not Done 1. MEDICAL: Soft tissue injury 2. MEDICAL: Symptomatic BPH 3. MEDICAL: Chronic liver disease 4. MEDICAL: Orthostatic hypotension 5. FUNCTIONAL: Accidental fall 6. FUNCTIONAL: Fear of falling 7. FUNCTIONAL: Postprandial hypotension 8. FUNCTIONAL: Gait disorder 9. FUNCTIONAL: Polypharmacy 10. FUNCTIONAL: Environmental hazards 11. PSYCHOLOGICAL: Possible alcohol abuse 12. PSYCHOLOGICAL: Depression 13. SOCIAL: Advance care planning TREATMENT (MANAGEMENT) Mention whether medical, functional, psychological or social-spiritual

Done Not Done

1. MEDICAL: Repeat liver function tests 2. MEDICAL: Alcohol withdrawal precautions 3. MEDICAL: Advise to quit drinking 4. MEDICAL: Discontinue or reduce terazosin, start tamsulosin 5. MEDICAL: Sleep hygiene 6. FUNCTIONAL: Fall precautions 7. FUNCTIONAL: Discontinue temazepam 8. FUNCTIONAL: Gait and balance training/Physical therapy 9. FUNCTIONAL: Reduce or discontinue hydrochlorothiazide 10. FUNCTIONAL: Environmental modification/home safety assessment 11. FUNCTIONAL: Start calcium and vitamin D 12. FUNCTIONAL: Fall monitoring system 13. FUNCTIONAL: Fall education 14. FUNCTIONAL: Bedside commode 15. FUNCTIONAL: Non-slip shoes 16. FUNCTIONAL: Reduce fluid intake at bedtime 17. FUNCTIONAL: Ophthalmologic evaluation 18. PSYCHOLOGICAL: Antidepressant therapy or referral to psychiatry COMMENTS


of 193

Fellow:



of 193

Station 12: Rehabilitation Potential Issue Assessing and managing rehabilitation potential in patients Presenting Situation A woman hospitalized for pneumonia and COPD exacerbation has been stabilized medically but is deconditioned and in need of appropriate discharge planning based on the fellow’s impression of her rehabilitation potential. Activity Computer-based patient management problems (Clinical vignettes) Time Required 20 minutes This station was developed by Renuka Tunuguntla, MD Enrique Aguilar, MD


of 193


Brief Case Introduction: Mrs. Rosa Maria Gomez, a 78-year-old female, was found by her eldest son sleeping one afternoon. He thought she was disoriented upon waking up. Alarmed, he took her to her physician who found her listless with edema of both legs. The physician recommended hospitalization. At the hospital she was diagnosed to have pneumonia with dehydration and mild COPD exacerbation for which she was admitted to the medical floor. She was gently hydrated, treated with antibiotics for pneumonia, and received bronchodilators for COPD. You are called today after 6 days of hospitalization to evaluate the patient’s rehabilitation potential. The physical therapy consult states that “Mrs. Rosa Maria is deconditioned and needs physical therapy”. On the other hand, the medical resident states that the patient is medically stable.

Questions: Choose the appropriate range of questions in your opinion. Remember, these are the most important questions. PLEASE READ ALL THREE QUESTIONS, THEN ANSWER UNDER THE MOST SUITABLE HEADING BELOW. DO NOT MOVE AHEAD UNTIL YOU HAVE ENTERED YOUR ANSWERS. Question: History of Present Illness What are the 6 (Range 5-7) to 9 (Range 8-12) most important questions you want to ask this patient about his/her symptoms? Question: Past Medical History What are the 3 (Range 3-5) to 6 (Range 6-9) most important questions you want to know about his/her past medical history?


of 193

Question: Social-Family History What are the 3 (Range 3-5) to 6 (Range 6-9) most important questions you want to know about him/her as a person (his social history and other relevant issues)? SCREEN 3 History: In this portion of the vignette, you have to answer the previous three questions using a narrative format. You can add additional history if you wish. PLEASE CONTINUE READING THE VIGNETTE AND ANSWER THE QUESTION BELOW. DO NOT MOVE AHEAD UNTIL YOU HAVE ENTERED YOUR ANSWERS. Mrs. Rosa Maria Gomez is a 78-year-old widow who lives alone in her old two-story home. Her husband died 10 years ago. She only uses the stairs once in the morning and to go to bed each evening. Her children assisted her in adding a half-bathroom to the first floor. Her knees make ascending and descending the stairs quite a chore. She also must negotiate a stairway (12 steps) from her front door to the sidewalk. She has three wonderful sons who do her grocery shopping, take her to appointments, and assist her with handy work in the house. Every morning she does all of her laundry by hand and makes plenty of food just in case her sons and their families drop by. Overall, she considers her health to be better than most of her friends. She is a retired teacher and enjoys reading. She denies feeling depressed. She has degenerative joint disease (DJD) which has impaired her ability to use the stairs and her hands are slow because her knuckles are gnarled. Also, she cannot reach her overhead shelves in the kitchen or her hanged clothes in the closet. She had a bout of pneumonia last year and was subsequently diagnosed with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). She has had one cataract removed and is waiting for the other cataract to ripen. She wears bifocals. After 6 days of hospitalization she is afebrile and her other vital signs are stable. There is no evidence of respiratory distress, and her leg edema is resolving. She has not needed any oxygen for the past 72 hrs. Medications at this time are: enteric coated aspirin 81 mg once a day, albuterol- ipratropium MDI 2 puffs every 6 hours as needed, levofloxacin 500 mg once a day, lisinopril 20 mg once a day, and metoprolol XL 50 mg once day. During your evaluation, Mrs. Rosa Maria clearly states her wishes to return home with the support of her family. She has Medicare part A and B with supplemental insurance. She also receives a teachers’ pension.

Question: Physical Examination What are the 5 (Range 3-5) to 8 (Range 6-9) most important elements of the physical examination that need to be performed on this patient? (Please be very specific: for


of 193

example, do not say you would “examine the knee”, but say what you would look for when you examined the knee, for example: “examine the knee for redness, swelling, point tenderness”). SCREEN 4 Physical Examination: In this portion of the vignette, you present the physical findings. Be certain to include those that the fellow should have requested. Remember, these are the most important elements of the physical examination and should be presented in a narrative format. PLEASE CONTINUE READING THE VIGNETTE AND ANSWER THE QUESTION BELOW. DO NOT MOVE AHEAD UNTIL YOU HAVE ENTERED YOUR ANSWERS.

Physical Examination: She is awake, alert, and oriented to person and place. She appears mildly confused upon awakening and later in the day as per the nurses’ reports. Her vital signs are stable without orthostatic changes. Oxygen saturation is 95% on room air. Lung examination reveals left basilar rales. There is no JVD. Hepatomegaly is present with 1+ edema in lower extremities. S1 and S2 are normal with no S3 or S4. Abdomen is soft and non tender. Rectal exam reveals hemorrhoids, and a small amount of stool, guaiac negative. Strength is 4/5 in both lower extremities and 5/5 in both upper extremities. GDS is 4/15 and MMSE is 24/30 (she was able to follow the 3 step command and recalled 2/3 words). Physical Therapy Evaluation: Patient experiences pain at all ranges in her shoulder, fingers, and knees. She would rate the pain as 4 at rest and as 7 during activity. Balance: seated, she has good static balance and can complete minimum to moderate excursions safely. Standing balance is good for static and minimum excursions. Balance is affected by poor endurance. Bed mobility: Rolling required minimal assistance. Supine to sit required moderate assistance. Transfers: Sit to stand, bed to walker, chair to walker require minimal assistance with minimal cues. Self care (right dominant): able to independently feed herself, perform all grooming, and dress herself with moderate assistance for her upper body and maximal assistance for her lower body. She needs moderate assistance for bathing and toileting. Mrs. Rosa states that her goals of physical therapy were: "to be able to go to the bathroom by myself, walk without a walker, and get home within a week."

Question: Diagnostic Work-up At this point, what consults, laboratory tests, or imaging studies would you order?


of 193

SCREEN 5 Diagnostic Testing: In this portion of the vignette, you present the diagnostic test findings. Be certain to include those findings that the fellow should have requested. Remember this is a narrative format.

PLEASE CONTINUE READING THE VIGNETTE AND ANSWER THE QUESTIONS BELOW. DO NOT MOVE AHEAD UNTIL YOU HAVE ENTERED YOUR ANSWERS.

Diagnostic Testing: Leukocytosis found at admission is now resolved. CBC is normal. Electrolytes, TSH, and liver function tests are within normal range. B12 and folate are within normal limits. RPR is negative. Chest X-ray shows cardiomegaly, and the infiltrate is reducing in size as compared to admission X ray. Echocardiogram reveals an ejection fraction of 25%.



of 193

PMP SCORING SHEET

Checklist: Rehabilitation Potential Station 12

Please write each item in the history, physical exam, diagnostic testing, diagnosis and treatment in the space provided. HISTORY Done Not Done 1. Evidence of delirium 2. Functional status (ADLs, IADLs) before hospitalization 3. Functional status (ADLs, IADLs) during hospitalization 4. Strength/endurance 5. Pain 6. Mood 7. Cognitive impairment/memory loss 8. Medications 9. Motivation 10. CHF symptoms like dyspnea, chest pain, orthopnea, any recent

exacerbations and hospitalizations

11. COPD symptoms and response to management 12. History of osteoarthritis 13. Living situation 14. Family support 15. Educational level 16. Financial/economic status PHYSICAL EXAM Done Not Done 1. Pain level 2. Musculoskeletal exam 3. Skin 4. Sensory exam 5. MMSE 6. Orthostatics 7. Cardiovascular exam 8. Pulmonary exam 9. Gait and balance 10. Neurological 11. CAM 12. GDS 13. Rectal exam


of 193

DIAGNOSTIC TESTING Done Not Done 1. CBC 2. TSH 3. Folate 4. RPR 5. Electrolytes, BUN and Creatinine 6. UA 7. Chest X rays 8. Liver function tests 9. Pulmonary function tests 10. EKG/ETT DIAGNOSIS Done Not Done 1. MEDICAL: Congestive heart failure, systolic 2. MEDICAL: COPD 3. MEDICAL: Osteoarthritis 4. MEDICAL: Uncontrolled pain 5. FUNCTIONAL: Sensory Impairment like cataracts 6. FUNCTIONAL: Deconditioning 7. FUNCTIONAL: Self-care deficits-be specific in what ADLS-IADLS 8. PSYCHOLOGICAL: Cognitive impairment 9. PSYCHOLOGICAL: Mood-adjustment disorder 10. SOCIAL: Living situation 11. SOCIAL: Good family support 12. SOCIAL: Good socioeconomic status 13. SOCIAL: Advance care planning TREATMENT (MANAGEMENT) Mention whether medical, functional, psychological or social-spiritual

Done Not Done

1. MEDICAL: Maximize analgesic therapy 2. FUNCTIONAL: Low level rehabilitation in Nursing Home-skilled nursing or

subacute care facility followed by discharge to home once she improves.

3. FUNCTIONAL: refer to ophthalmology for evaluation and management 4. FUNCTIONAL: Durable medical equipment like a cane or walker and

equipment for ADLS depending on her progress.

5. FUNCTIONAL: Home evaluation and modifications as low shelves in the kitchen, lower level of rod for hanging clothes in the closet etc needs to be modified.

6. PSCYHOLOGICAL: Consider cholinesterase inhibitors, education about dementia. Repeat MMSE.

7. SOCIAL: Advance care planning COMMENTS:


of 193

Fellow:



of 193

Station 13: Placement Decisions Issue Determine placement for patients after hospitalization Presenting Situation A patient in the hospital is in need of appropriate discharge planning after surgical repair of a traumatic hip fracture. Activity Computer-based patient management problems (Clinical vignettes) Time Required 20 minutes This station was developed by Renuka Tunuguntla, MD Enrique Aguilar, MD


of 193


Brief Case Introduction: Mr. George Farmer, a 78-year-old male, is admitted to the orthopedic service after falling and fracturing his right hip. He underwent a right ORIF without complications. After surgery, he begins receiving rehabilitation but is participating poorly. Orthopedic Surgeons decided to consult the Geriatrics Service to assist them with discharge planning.

Questions: Choose the appropriate range of questions in your opinion. Remember, these are the most important questions. PLEASE READ ALL THREE QUESTIONS, THEN ANSWER UNDER THE MOST SUITABLE HEADING BELOW. DO NOT MOVE AHEAD UNTIL YOU HAVE ENTERED YOUR ANSWERS. Question: History of Present Illness What are the 5 (Range 5-7) to 8 (Range 8-12) most important questions you want to ask this patient about his/her symptoms? Question: Past Medical History What are the 3 (Range 3-5) to 5 (Range 6-9) most important questions you want to know about his/her past medical history? Question: Social-Family History What are the 3 (Range 3-5) to 5 (Range 6-9) most important questions you want to know about him/her as a person (his social history and other relevant issues)? SCREEN 3 History: In this portion of the vignette, you have to answer the previous three questions using a narrative format. You can add additional history if you wish.


of 193

PLEASE CONTINUE READING THE VIGNETTE AND ANSWER THE QUESTION BELOW. DO NOT MOVE AHEAD UNTIL YOU HAVE ENTERED YOUR ANSWERS. History: Mr. George Farmer, a 78-year old male, is admitted to the orthopedic service after he sustained a fall and fractured his right hip. He woke up at night to go to bathroom when he tripped and fell. He underwent a right ORIF. After surgery, he started receiving rehabilitation but his participation in therapy has been close to minimal, and he is afraid to get out of bed. He has lost 2 lbs in the last 2 weeks. Mr. Farmer rarely eats more than 25-50% of meals. He feels very tired and reports insomnia. Upon further questioning, he says that he has a lot of pain, especially at night. He is disappointed that he is not able to do well in rehab. His personal aim is to gain strength and go home. He understands the importance of doing the exercises. Past Medical History: hypertension, osteoarthritis of the left knee, and hypercholesterolemia. Medications: hydrochlorothiazide 25 mg daily, acetaminophen 500 mg every 6 hrs as needed, atorvastatin 10 mg at bedtime, and calcium carbonate/vitamin D daily Functional history: Prior to admission, Mr. Farmer lived alone and ambulated without an assistive device. He was independent for all his ADLs but partially dependent for some of his IADLs. His daughter assisted him in doing the housework and grocery shopping. Now that he is in the hospital, he is dependent for all of his ADLs except feeding. He needs assistance in grooming, dressing, toileting and bathing. Social: He went to college. He is a widower; his wife died 5 yrs ago. He has a supportive daughter who lives nearby and checks on him often. He used to enjoy going to church. He denies smoking, alcohol, or other recreational drugs. He has Medicare with supplemental insurance. He also has a retirement plan and a pension.

Question: Physical Examination What are the 4 (Range 3-5) to 8 (Range 6-9) most important elements of the physical examination that need to be performed on this patient? (Please be very specific: for example, do not say you would “examine the knee”, but say what you would look for when you examined the knee, for example: “examine the knee for redness, swelling, point tenderness”). SCREEN 4 Physical Examination: In this portion of the vignette, you present the physical findings. Be certain to include those that the fellow should have requested. Remember, these are the most important elements of the physical examination and should be presented in a narrative format. PLEASE CONTINUE READING THE VIGNETTE AND ANSWER THE QUESTION BELOW. DO NOT MOVE AHEAD UNTIL YOU HAVE ENTERED YOUR ANSWERS.


of 193

Physical Examination: The patient is awake, alert, and cooperative. Vitals: pulse 72, BP 148/82 with no orthostasis, respiratory rate 16, afebrile, and average pain score 7 (highest 9 during PT, lowest 5). Cardiovascular: regular rate and rhythm, no murmurs/rubs/ gallops. Respiratory: clear, no rales or rhonchi. Musculoskeletal: right hip has limited range of motion and is painful. No signs of infection. Left knee crepitus is present. No pedal edema. Rectal: small amount of soft stool, guaiac negative. Neurological: awake and oriented to person and place. Sensation is intact, strength 4/5 in both lower extremities and 5/5 in both upper extremities. GDS 6/15, MMSE 23/30. He was able to follow a 3-step command but missed points in orientation, recalled 1 out of 3 words, and failed to draw the intersecting pentagons.


Diagnostic Testing: CBC shows mild lymphopenia, BMP, TSH and UA are within normal limits. Cholesterol 140, albumin 3.0. X-rays of the left knee indicate advanced osteoarthritis. B12 and folate are within normal limits. RPR is negative.



of 193

PMP SCORING SHEET

Checklist: Placement Station 13

Please write each item in the history, physical exam, diagnostic testing, diagnosis and treatment in the space provided. HISTORY Done Not Done 1. Pain level 2. Circumstances of the fall 3. Motivation 4. Nutritional status 5. Functional status (ADLs-IADLs) before hospitalization 6. Functional status (ADLs-IADLs) during hospitalization 7. Medications 8. Mood 9. Cognitive status 10. Fear of falling 11. Frequent falls 12. Urinary symptoms like urgency, nocturia, frequency, and incontinence 13. Mobility 14. Living situation 15. Family support 16. Alcohol, drugs 17. Financial status: insurance? PHYSICAL EXAM Done Not Done 1. Vital signs 2. Orthostatics 3. Cardiovascular exam 4. Respiratory exam 5. Musculoskeletal exam not only of the limb affected but condition of the

other or healthy limb as he has OA and he needs rehab

6. Neurological- looking for any sensory or motor deficit 7. GDS 8. MMSE 9. Rectal exam 10. Pain level 11. Gait and balance


of 193

DIAGNOSTIC TESTING Done Not Done 1. CBC 2. BMP 3. TSH 4. Liver function tests 5. X rays of left knee 6. Folate 7. B12 8. RPR DIAGNOSIS Done Not Done 1. MEDICAL: Hip fracture of right hip s/p surgery 2. MEDICAL: Uncontrolled pain 3. MEDICAL: Osteoarthritis of the left knee 4. MEDICAL: Weight loss, consider malnutrition or anorexia 5. MEDICAL: Sensory problems 6. FUNCTIONAL: Falls 7. FUNCTIONAL: Self-care deficit-be specific about ADLs, IADLs 8. PSYCHOLOGICAL: Cognitive impairment 9. PSYCHOLOGICAL: Consider depression 10. PSYCHOLOGICAL: Fear of falling 11. SOCIAL: Social support 12. SOCIAL: Advance care planning TREATMENT (MANAGEMENT) Mention whether medical, functional, psychological or social-spiritual

Done Not Done

1. MEDICAL: Nutritional supplement in between meals 2. MEDICAL: Pain management with tramadol or combination meds like

Vicodin or Percocet around the clock and for breakthrough pain

3. MEDICAL: Dietetics consult 4. FUNCTIONAL: Physical and occupational therapy 5. FUNCTIONAL: NH placement for low level rehab at this time optimal in

view of low energy but good potential as he was previously functional, living independently, is motivated, and wants to go home

6. FUNCTIONAL: Fall precautions 7. FUNCTIONAL: Home safety evaluation later 8. PSYCHOLOGICAL: Consider treatment for dementia 9. PSYCHOLOGICAL: Consider treatment for depression 10. SOCIAL: Communicate your plans with patient/family about NH placement COMMENTS


of 193

Fellow:



of 193

Station 14: Delirium Issue Assessing and managing patients with delirium Presenting Situation A patient presents to the emergency department with delirium. Activity Computer-based patient management problems (Clinical vignettes) Time Required 20 minutes This station was developed by Marcos Milanez, MD


of 193


Brief Case Introduction: Mrs. Emma Morton, a 73-year-old female, is brought in by ambulance with a chief complaint of "worrying about having heart or kidney failure." The patient states she has not been able to sleep for several months secondary to these preoccupations. She also reports decreased appetite, feeling as if food is getting stuck in her throat, and decreased oral intake for the past 2 days. Because she was unable to give a coherent history, the remaining history was obtained from the patient's sister with whom she lives. Her sister reports that she developed a subjective high fever, headache, nausea, vomiting, and abdominal pain 2 weeks ago. Approximately 1 week prior to presentation, the sister noticed that Ms. Morton developed an abrupt change in mental status and became very agitated at times. During the past week, she has had two low-grade fevers of 100°F.

Questions: Choose the appropriate range of questions in your opinion. Remember, these are the most important questions. PLEASE READ ALL THREE QUESTIONS, THEN ANSWER UNDER THE MOST SUITABLE HEADING BELOW. DO NOT MOVE AHEAD UNTIL YOU HAVE ENTERED YOUR ANSWERS. Question: History of Present Illness What are the 5 (Range 5-7) to 8 (Range 8-12) most important questions you want to ask this patient about his/her symptoms? Question: Past Medical History What are the 4 (Range 3-5) to 6 (Range 6-9) most important questions you want to know about his/her past medical history?


of 193

Question: Social-Family History What are the 3 (Range 3-5) to 6 (Range 6-9) most important questions you want to know about him/her as a person (his social history and other relevant issues)? SCREEN 3 History: In this portion of the vignette, you have to answer the previous three questions using a narrative format. You can add additional history if you wish. PLEASE CONTINUE READING THE VIGNETTE AND ANSWER THE QUESTION BELOW. DO NOT MOVE AHEAD UNTIL YOU HAVE ENTERED YOUR ANSWERS. The patient's sister felt she was "burning up" and observed chills. The patient was unable to sleep and would not eat. The patient then saw her physician who prescribed ciprofloxacin. Thereafter, she reportedly developed an unnamed "allergic reaction" and stopped taking the antibiotic. She was then given another unknown medication, which she also stopped due to another "allergic reaction." In the emergency department, the patient denies headache, fever, chills, nausea, vomiting, vision changes, chest pain, or shortness of breath. Her past medical history includes 2 ischemic strokes several years prior with no residual deficits, peptic ulcer disease, diverticulosis, benign tremor, gastroesophageal reflux disease, asthma, emphysema, tachyarrhythmia, macular degeneration, osteoarthritis, hypertension, rheumatoid arthritis, diabetes, gout, and hyperlipidemia. She also has a chronic anxiety disorder, hypochondriasis, and depression. The patient's sister stated that she has an "agitative personality," and that this behavior has been progressing over the past year. At baseline, she was able to independently complete all of her activities of daily living and instrumental activities of daily living and helped care for her sister, who has breast cancer. She wears glasses for presbyopia and hearing aids due to progressive hearing loss. The patient formerly worked as a commercial artist. She previously smoked but did not drink alcohol. Her medications include belladonna, trazodone, carisoprodol, citalopram, diazepam, furosemide, lansoprazole, albuterol, acetylsalicylic acid, salmeterol, and benazepril. Her reported allergies include penicillin, sulfa, tetracycline, and ciprofloxacin. The nurses saw her that afternoon and reported that she slept for several hours. The night shift nurses reported that the patient was very restless and agitated. She was incoherent at times and asking for her mother (she died 20 years ago).

Question: Physical Examination What are the 5 (Range 3-5) to 7 (Range 6-9) most important elements of the physical examination that need to be performed on this patient? (Please be very specific: for example, do not say you would “examine the knee”, but say what you would look for


of 193

when you examined the knee, for example: “examine the knee for redness, swelling, point tenderness”). SCREEN 4 Physical Examination: In this portion of the vignette, you present the physical findings. Be certain to include those that the fellow should have requested. Remember, these are the most important elements of the physical examination and should be presented in a narrative format. PLEASE CONTINUE READING THE VIGNETTE AND ANSWER THE QUESTION BELOW. DO NOT MOVE AHEAD UNTIL YOU HAVE ENTERED YOUR ANSWERS.

Physical Examination: The vital signs include temperature of 98.6°F, blood pressure ranging from 220 to 153 mm Hg systolic and 79 to 66 mm Hg diastolic, and heart rate ranging from 118 to 80 beats per minute. She was breathing comfortably with 98% oxygen saturation on room air. The patient was alert, awake, and oriented to self and general place only. She was very anxious and verbose with tangential speech. The head, neck, lungs, heart, abdomen, skin and extremities were unremarkable. Her neurological examination showed a generalized resting tremor, but was otherwise non-focal, and she had no nuchal rigidity. She could ambulate without assistance but needed redirection. MMSE was 20 (she could not register 2 words, was disoriented to time, could not perform the 3-step command, and failed to draw the intersecting pentagons). MMSE one year ago was 28/30. GDS could not be completed.


Diagnostic Testing: Laboratory studies in the emergency department showed a white blood cell count of 8.9 with 77% neutrophils, 13% lymphocytes and 8% monocytes. Electrolyte panel revealed sodium of 127, potassium of 3.6, chloride of 92, bicarbonate of 26, urea nitrogen 7 and creatinine of 0.7, and calcium of 8.8. Urinalysis was notable for 2+ ketones, trace blood, 6 red blood cells and 50-100 white blood cells. An arterial blood gas was normal. B12 and folate were normal. RPR was negative. TSH: 3.0. Urine toxicity screen was positive for


of 193

barbiturates. Chest X ray showed no infiltrates. Electrocardiogram was unremarkable. A non-contrast head CT scan was negative for infarct, bleed, mass effect, or hydrocephalus. After evaluation in the emergency department, the patient was admitted to Jackson Memorial. The ER physician ordered wrist restraints.



of 193

PMP SCORING SHEET

Checklist: Delirium Station 14

Please write each item in the history, physical exam, diagnostic testing, diagnosis and treatment in the space provided. HISTORY Done Not Done 1. Previous history of delirium 2. Acute 3. Fluctuating course 4. Poor Attention 5. Confusion 6. ADLs 7. IADLs 8. Medications 9. Recent medication changes 10. Sleep pattern 11. Oral intake 12. Psychomotor agitation 13. Hypoactive 14. Chronic medical problems 15. Depressed mood 16. Memory loss-forgetfulness 17. History of stroke 18. History of psychiatric disorder 19. Falls 20. OTCs 21. Educational level 22. Occupation 23. Alcohol 24. Illicit Drugs 25. Advance directives 26. Support system 27. Family history of Alzheimer's disease? 28. Head trauma 29. Seizures PHYSICAL EXAM Done Not Done 1. Vital signs 2. Orthostatics 3. Neurological 4. Postvoid residual volume 5. Cardiovascular 6. Respiratory 7. Abdominal exam, looking for signs of acute abdomen/palpable bladder 8. Gait and balance exam 9. Rectal examination


of 193

DIAGNOSTIC TESTING Done Not Done 1. CBC 2. CMP 3. UA 4. TSH 5. Chest X rays 6. EKG 7. Urine toxicology screen 8. Salicylate level 9. Brain CT 10. B12, folate, RPR 11. ABG DIAGNOSIS Done Not Done 1. MEDICAL: Delirium 2. MEDICAL: UTI 3. MEDICAL: Electrolyte disturbance 4. MEDICAL: Infection 5. MEDICAL: Hypertension and tachycardia 6. FUNCTIONAL: Polypharmacy 7. PSYCHOLOGICAL: Possible dementia 8. PSYCHOLOGICAL: Depression/possible suicide attempt 9. SOCIAL: Risk of caregiver burden 10. SOCIAL: Advance care planning TREATMENT (MANAGEMENT) Mention whether medical, functional, psychological or social-spiritual

Done Not Done

1. MEDICAL: Treat UTI 2. MEDICAL: Adequate hydration 3. MEDICAL: Adequate nutrition 4. MEDICAL: Frequent orientation/visits by familiar faces 5. MEDICAL: Environmental adjustments (light, noise) 6. MEDICAL: Sleep hygiene 7. MEDICAL: Avoid restraints 8. MEDICAL: One-on-one companion 9. MEDICAL: Discontinue belladonna 10. MEDICAL: Discontinue trazodone 11. MEDICAL: Discontinue carisoprodol 12. MEDICAL: Discontinue acetylsalicylic acid 13. MEDICAL: Titrate down benzodiazepines 14. FUNCTIONAL: Sensory aids 15. FUNCTIONAL: Early mobilization/physical therapy 16. PSYCHOLOGICAL: Repeat MMSE 17. SOCIAL: Caregiver education and referral to caregiver support services COMMENTS


of 193

Fellow:



of 193

Station 15: Chronic Pain Issue Assessing patients with chronic pain Presenting Situation A patient with prostate cancer reports bone pain at a routine outpatient follow-up visit. Activity Computer-based patient management problems (Clinical vignettes) Time Required 20 minutes This station was developed by Khin Zaw, M.D. Jorge Ruiz, M.D.


of 193


Brief Case Introduction: Mr. Arthur Johnson is a 76-year-old male who was diagnosed with locally extensive prostate cancer four years ago (Gleason score 4 + 4 = 8). He received radiation therapy, later underwent orchiectomy, and then received flutamide for recurrence. The disease is now refractory to any therapy. During a routine office visit, Mr. Johnson reports generalized aching pain in his bones.



of 193

PLEASE CONTINUE READING THE VIGNETTE AND ANSWER THE QUESTION BELOW. DO NOT MOVE AHEAD UNTIL YOU HAVE ENTERED YOUR ANSWERS. While sitting quietly in a chair in the office and appearing tired but not in distress, Mr. Johnson reports that his pain level is now 9, the average intensity of his pain is 9 and his worst pain is at least 10. For a few hours after he takes acetaminophen, his pain level falls to 8. Upon further questioning, he reports that his pain is aching and gnawing, occurs almost all day, mostly in his hips, thighs and mid-back. At its worst, it becomes more generalized and his whole body hurts. It exacerbates with movements and feels slightly relieved when he stays undisturbed or is distracted by talking, for example. He is afraid that his cancer is getting worse and has become widespread. His wife reports that he is sleeping badly, is irritable, is almost always confined to his recliner, and cannot attend church regularly. He no longer enjoys reading and watching television news as he always used to. Aside from peptic ulcer disease, he has no other comorbid conditions. He takes omeprazole 40 mg daily and acetaminophen for his pain. A few weeks ago, he tried over-the-counter ibuprofen 2 tablets of 200 mg 3 times a day. He felt better pain relief but he had to quit taking it within a few days due to development of epigastric pain. Although he wants complete pain relief, he wishes not to take any "heavy duty" medications such as morphine. He is married and lives with his wife who is his primary caregiver. Their two daughters live in town and their friends from church support them. He denies illicit drug use, and he is social drinker.



of 193

Physical Examination: Elderly, mildly cachectic, thin gentleman sitting in a chair quietly who does not appear to be in acute distress. Temporal wasting is noted. Vital signs are normal with no orthostatic changes. He looks sad and does not volunteer in conversation. His wife helps him to get out of the chair, and he uses a cane to ambulate a short distance. He walks with difficulty, and his gait is slow due to pain. Hips and thighs are tender to touch. Range of motion at hips is limited due to pain. There is a focal tenderness at the T11-12 area. Focused neurological examination shows no clinical evidence of epidural cord compression. Post-void urine <25 cc of urine and normal sphincter tone. Rectal vault is empty, guaiac negative stool. Hard, enlarged prostate with irregular surface on DRE. The remainder of the exam is unremarkable. His mini-mental state examination (MMSE) is 28/30 and GDS is 9/15.


Diagnostic Testing: Comprehensive metabolic panel shows mildly elevated ratio of BUN/Cr but is otherwise unremarkable. Complete blood count shows mild anemia (hematocrit 30). X-rays of the spine show metastatic lesions at T11, 12, and L1 and the pedicles are intact. The x-rays of hips and thighs show metastatic lesions and no fracture. The MRI of the spine no evidence of epidural compression.



of 193

PMP SCORING SHEET Checklist: Chronic Pain

Station 15 Please write each item in the history, physical exam, diagnostic testing, diagnosis and treatment in the space provided. HISTORY Done Not Done 1. Onset of pain 2. Location of pain 3. Duration of pain 4. Characteristics of pain 5. Aggravating factors 6. Relieving factors 7. Temporal association – to include basal and breakthrough pain 8. Severity of pain – to include pain at its worst, least, on average, and right

now

9. Functional impairment secondary to pain 10. Impact on psychological well-being secondary to pain 11. Impact on social well-being secondary to pain 12. Impact on spiritual well-being secondary to pain 13. GI – presence of PUD, bleeding history 14. Renal – presence of renal insufficiency and renal failure 15. Hematologic – history of bleeding diathesis, platelet dysfunction, anemia 16. Current medication – to include pain meds, polypharmacy 17. Nature of response to current pain medication 18. History of adverse reactions to opioids or other analgesics 19. Meaning of the pain – what does the pain mean to the patient? 20. Goal of treatment – pain relief, functional restoration, life prolongation? 21. Patient’s preferences and acceptance to opioid therapy 22. History of alcohol and illicit drug use 23. Assessment of social support system – formal and informal support PHYSICAL EXAM Done Not Done 1. Vital signs 2. General assessment of performance status, physical distress, and mood 3. General examination – include gait, functional impairment 4. Focused neurologic examination to evaluate for spinal cord compression 5. Musculoskeletal - local tenderness, range of motion 6. Rectal


of 193

DIAGNOSTIC TESTING Done Not Done 1. Radiograph of the spine 2. Radiograph of the hips 3. Comprehensive metabolic panel (CMP) 4. Complete blood count (CBC) 5. MRI of the spine DIAGNOSIS Done Not Done 1. MEDICAL: Severe pain secondary to metastatic prostate cancer to the

bones

2. MEDICAL: Malnutrition secondary to malignancy 3. FUNCTIONAL: Functional impairment secondary to bone pain 4. FUNCTIONAL: Impaired quality of life secondary to pain and advanced

prostate cancer

5. PSYCHOLOGICAL: Depression secondary to pain and advanced prostate cancer

6. SOCIAL: Caregiver stress and burden 7. SOCIAL: Spiritual dilemma due to unrelenting pain and suffering 8. SOCIAL: Advance Care Planning TREATMENT (MANAGEMENT) Mention whether medical, functional, psychological or social-spiritual

Done Not Done

1. MEDICAL: start on opioids for severe pain. 2. MEDICAL: strategy involves initiation with short acting opioids around the

clock e.g. morphine IR 10-30 mg PO Q4H PRN with senna 17.2 mg PO HS for bowel regimen, then switch later to morphine SR 30-90 mg PO Q12H with morphine IR 10-20 mg PO Q2H PRN for breakthrough pain.

3. MEDICAL: Liberalize diet + oral supplements 4. MEDICAL: Educate about opioids 5. MEDICAL: Use of adjuvant analgesics for bone pain such as NSAIDs with

GI prophylaxis should be considered (however, this particular patient is unable to tolerate).

6. FUNCTIONAL: Non-pharmacologic approaches involve heating pad, lift, distraction, cognitive behavioral therapy

7. FUNCTIONAL: Assistive device for difficulty ambulating and gait disturbance such as walker, physical therapy evaluation may be helpful to improve functional independence. Impaired sleep and quality of life should improve with adequate pain control.

8. PSYCHOLOGICAL: Adequate pain control will help to improve depression. In addition, psychological intervention will be helpful in this situation. If the response is inadequate, use of SSRI may be indicated.

9. SOCIAL-SPIRITUAL: Support by religious community (e.g. church) will help to reduce caregiver burden and specific intervention by spiritual leader (pastor) may be helpful to alleviate suffering

10. SOCIAL-SPIRITUAL: Hospice referral COMMENTS


of 193

Fellow:



of 193

Station 16: Depression Issue Assessing and managing patients with depression Presenting Situation A patient with depressive symptoms is seen in the outpatient clinic with his daughter. Activity Computer-based patient management problems (Clinical vignettes) Time Required 20 minutes This station was developed by Juan Carlos Palacios, MD Jorge Ruiz, MD


of 193


Brief Case Introduction: Mr. Fred Hollis is a 69-year-old male who comes to your office accompanied by his daughter. Mr. Hollis explains that he really hasn’t felt well since his heart attack 4 months ago. A few days after the event, he tried hard to throw himself back into life. He wanted to return to usual activities. He tells you that his father died of a heart attack at 65. Here he is at 69, and as he puts it, “I am living on borrowed time. I am getting old. There is nothing I want to do. I’m a big burden on my daughter.”

Questions: Choose the appropriate range of questions in your opinion. Remember, these are the most important questions. PLEASE READ ALL THREE QUESTIONS, THEN ANSWER UNDER THE MOST SUITABLE HEADING BELOW. DO NOT MOVE AHEAD UNTIL YOU HAVE ENTERED YOUR ANSWERS. Question: History of Present Illness What are the 7 (Range 5-7) to 12 (Range 8-12) most important questions you want to ask this patient about his/her symptoms? Question: Past Medical History What are the 3 (Range 3-5) to 6 (Range 6-9) most important questions you want to know about his/her past medical history? Question: Social-Family History What are the 3 (Range 3-5) to 6 (Range 6-9) most important questions you want to know about him/her as a person (his social history and other relevant issues)?


of 193

SCREEN 3 History: In this portion of the vignette, you have to answer the previous three questions using a narrative format. You can add additional history if you wish. PLEASE CONTINUE READING THE VIGNETTE AND ANSWER THE QUESTION BELOW. DO NOT MOVE AHEAD UNTIL YOU HAVE ENTERED YOUR ANSWERS. On further evaluation Mr. Hollis states that he feels hopeless about the future. He feels so bad that sometimes he believes that life is not worth living. “Well doctor, it seems bleak. I feel down most of the time.” He finds himself thinking about death a lot. When asked about whether he has ever thought about taking his own life, he states, “I would never kill myself. I wish I would just go in my sleep. That would be fine. But I could never deliberately harm myself. That would be a terrible thing to do to my family.” He feels drained, and his energy level is low. He usually enjoys going fishing, reading mystery novels, and playing pool in his basement but he no longer feels like doing any of those activities. His daughter sometimes encourages him to read but he has trouble following the plot of the story. He sleeps for most of the day but at night he has trouble falling asleep and when he does, he awakens many times. His daughter has also noticed that he barely touches his food. He was discharged from the hospital 4 months ago due to an inferior acute myocardial infarction. Mr. Hollis is independent in all his ADLs. He needs some assistance from his daughter to pay bills, and she also prepares pillboxes so he can remember to take his medications. During hospitalization, his metoprolol was increased to 100 mg twice a day, he was started on aspirin 81 mg once a day, lisinopril 10 mg once a day, alprazolam 0.5 mg twice a day, Tylenol PM (acetaminophen + diphenhydramine) at bedtime and cimetidine 300 mg twice a day.



of 193

Physical Examination: In general, he looks sad. Although his vocabulary is excellent and his speech fluent, Mr. Hollis speaks slowly and often stops talking in mid-thought. Vital signs are within normal limits with no orthostatic changes. Weight: 160 lbs (down from 172 lbs. 3 months ago). Pain level: 2/10. Skin: warm and dry. Cardiovascular: regular rhythm and rate, no murmurs or gallops. Respiratory: clear to auscultation. Abdomen: soft, non-tender, normal bowel sounds, no hepatosplenomegaly. Rectal: no masses, soft stool, guaiac negative. Neurological: muscle strength, sensation, cranial nerves, gait, and coordination were all normal. No tremors. MMSE: 29/30 (he was off by two days on the date). GDS: 12/15.


Diagnostic Testing: CBC and BMP were normal. Cholesterol is 150, albumin 2.8, TSH 3.0, vitamin B12 level 500, and normal folate.



of 193

PMP SCORING SHEET

Checklist: Depression Station 16

Please write each item in the history, physical exam, diagnostic testing, diagnosis and treatment in the space provided. HISTORY Done Not Done 1. Sleep disorder (either increased or decreased sleep) 2. Interest deficit (anhedonia) 3. Guilt (worthlessness, hopelessness, regret) 4. Energy deficit 5. Concentration deficit 6. Appetite disorder (either decreased or increased) 7. Suicidality 8. Constipation 9. Sadness, mood change 10. Weight loss 11. Medications 12. Tremor 13. Gait disorder 14. Falls 15. Recent hospitalization 16. Recent losses 17. Onset-duration 18. Alleviating factors 19. Palpitations 20. Cardiovascular symptoms: dyspnea, chest pain 21. History of depression 22. Family support 23. Spirituality PHYSICAL EXAM Done Not Done 1. Vital signs 2. Skin 3. Cardiovascular 4. Respiratory 5. Abdomen 6. Rectal 7. MMSE 8. GDS 9. Neurological


of 193

DIAGNOSTIC TESTING Done Not Done 1. CBC 2. BMP 3. Liver function tests-albumin 4. TSH 5. UA 6. B12 DIAGNOSIS Done Not Done 1. MEDICAL: Coronary disease 2. MEDICAL: Malnutrition 3. FUNCTIONAL: Polypharmacy 4. PSYCHOLOGICAL: Major depression 5. SOCIAL: Good support 6. SOCIAL: Advance care planning TREATMENT (MANAGEMENT) Mention whether medical, functional, psychological or social-spiritual

Done Not Done

1. MEDICAL: Switch to another beta blocker 2. MEDICAL: Oral nutritional supplements 3. FUNCTIONAL: Discontinue Tylenol PM 4. PSYCHOLOGICAL: Discontinue or titrate down alprazolam 5. PSYCHOLOGICAL: Refer to psychiatry or start antidepressant therapy 6. PSYCHOLOGICAL: Education COMMENTS


of 193

Fellow:



of 193

Station 17: Dizziness Issue Assessing and managing patients with dizziness Presenting Situation A patient presents to the outpatient clinic with dizziness. Activity Computer-based patient management problems (Clinical vignettes) Time Required 20 minutes This station was developed by Regina Marranzini, MD Paul Cherniack, MD


of 193


Brief Case Introduction: Mr. Arthur Bergman is a 75-year-old male who presents to your office with a five-day history of “dizzy spells.” He is concerned because he has a tennis match next week and wants to make sure nothing keeps him from winning.



of 193

PLEASE CONTINUE READING THE VIGNETTE AND ANSWER THE QUESTION BELOW. DO NOT MOVE AHEAD UNTIL YOU HAVE ENTERED YOUR ANSWERS. Mr. Bergman reports that each dizzy spell lasts about 15 seconds and interferes with his ability to work. He describes the attacks as sudden in onset, usually while lying in bed when he moves his head to the left causing a rotatory sensation. There is no real change in his symptoms when he sits up. He denies tinnitus, hearing loss, nausea, vomiting, loss of consciousness, fevers, or prior URI symptoms. He has occasional numbness in both hands without dizziness. He denies any depressive symptoms. His past medical history is remarkable only for hypertension, well controlled on a beta-blocker which is his only medication. He has not had any recent medication changes and has never had any adverse reactions to any medicines. He also takes ginkgo biloba , vitamin E and vitamin B12 as he strongly believes they keep him 'at the top of his game'. Other than a cholecystectomy, he denies any surgeries or hospitalizations and denies prior falls. No head trauma that he recalls. He lives with his 65-year-old wife who is also very active. They have 3 grown children; one of them lives 30 minutes away and visits often. He and his wife enjoy going out with friends, traveling abroad, and going to the opera (they just bought season tickets). He drives and has never had an accident. However, his wife states on their way to your office today, they got close to hitting a car. He does not smoke but enjoys the occasional rum and coke. He denies any relation of the dizziness episodes with the rum drinks as he only drinks one every two weeks. He has a healthy diet and drinks plenty of fluids.



of 193

Physical Examination: When asked to transfer from chair to the examining table, he arises without the use of his arms in two attempts and has a fairly stable gait. His vital signs are BP 150/85 and a pulse of 55 without orthostatic changes. He has good visual acuity as assessed by a Snellen eye chart. No nystagmus is noted. His tympanic membranes are both normal. Cardiovascular exam is normal without murmurs or bruits. The rest of his neurological exam is normal. Rectal exam is unremarkable with guaiac negative stool. After performing the Hall-Pike maneuver, he develops rotatory nystagmus after a 10-second latency period which reproduces his symptoms. Asking the patient to hyperventilate for 30 seconds does not reproduce his symptoms. MMSE 30/30 and GDS 0/15.

Question: Diagnostic Work-up At this point, what consults, laboratory tests, or imaging studies would you order? SCREEN 5 Diagnostic Testing (Narrative case vignette with diagnostic findings): In this portion of the vignette, you present the diagnostic test findings. Be certain to include those findings that the fellow should have requested. Remember this is a narrative format. PLEASE CONTINUE READING THE VIGNETTE AND ANSWER THE QUESTIONS BELOW. DO NOT MOVE AHEAD UNTIL YOU HAVE ENTERED YOUR ANSWERS.

Diagnostic Testing: The CMP returns with a creatinine of 0.8 and a BUN of 10. The remaining electrolytes are within normal limits. CBC is also within normal limits. The audiometry results are normal for his age.



of 193

PMP SCORING SHEET

Checklist: Dizziness Station 17

Please write each item in the history, physical exam, diagnostic testing, diagnosis and treatment in the space provided. HISTORY Done Not Done 1. Vertigo (perception of movement) 2. Disequilibrium (no abnormal perception of movement) 3. Lightheadedness 4. Syncope 5. Signs of infection 6. Mental status change 7. Fluid intake 8. GI bleeding: melena, rectal bleeding, hematemesis 9. CO exposure 10. Blurry vision 11. Tinnitus 12. Hearing loss 13. Symptoms reproduced by positional changes 14. Frequency 15. Mood 16. Functional impairment secondary to dizziness 17. Alleviating factors? provoking situation? (stress), provoking activity?

(standing, meds, head turning, walking)

18. Aggravating factors 19. History of falls 20. History of seizures 21. Medicines 22. Head trauma 23. Driving history. Accidents? 24. Alcohol or drug abuse PHYSICAL EXAM Done Not Done 1. Orthostatics 2. Vital signs 3. Cardiovascular 4. ENT exam (for otitis media, sinusitis, impaired hearing) 5. Eyes exam: nystagmus, Snellen eye chart 6. Neurologic exam: focal deficits 7. Rectal: stool occult blood testing 8. Dix- Hallpike maneuver 9. Gait assessment 10. Romberg 11. Cerebellar signs


of 193

DIAGNOSTIC TESTING Done Not Done 1. CBC 2. BMP 3. Liver function tests 4. ENG- electronystagmography 5. Audiometry DIAGNOSIS Done Not Done 1. MEDICAL: Benign Positional Vertigo 2. SOCIAL: Advance care planning TREATMENT (MANAGEMENT) Mention whether medical, functional, psychological or social-spiritual

Done Not Done

1. MEDICAL: Epley maneuver for BPV 2. MEDICAL: Education about BPV 3. MEDICAL: Educate about vitamins 4. FUNCTIONAL: Caution/avoidance with driving until after formal test for

driving safety done.

COMMENTS


of 193

Fellow:



of 193

Station 18: Malnutrition Issue Assessing and managing patients with malnutrition Presenting Situation A patient is brought to the outpatient clinic by his wife who reports poor appetite and weight loss. Activity Computer-based patient management problems (Clinical vignettes) Time Required 20 minutes This station was developed by Renuka Tunuguntla, MD


of 193


Brief Case Introduction: Mr. Berg is an 88-year-old male you are evaluating for the first time in the outpatient clinic. His wife reports that he is not eating and losing weight.



of 193

PLEASE CONTINUE READING THE VIGNETTE AND ANSWER THE QUESTION BELOW. DO NOT MOVE AHEAD UNTIL YOU HAVE ENTERED YOUR ANSWERS.

Mr. Berg has Alzheimer's disease and has had a poor appetite for the past 6 months. During this time period, he has lost over 20 lbs and his clothes no longer fit him properly. His wife notes no discomfort or coughing with swallowing. She does notice that he appears to be worrying more about things and has difficulty falling asleep at night. She reports that sometimes he cries for no reason. Medications include hydrochlorothiazide 25mg daily, aspirin 325mg daily, and a multivitamin daily. His past medical history includes a systolic heart murmur and colonic polyps. He also had a deep vein thrombosis of the right leg 1 year ago following right knee replacement surgery. There is no history of cancer or coronary artery disease. He is a retired postal worker who stopped smoking 32 years ago. He used to drink 3-4 drinks daily but stopped 8 years ago. No family history of cancer. He has Medicare with supplemental insurance. He also gets a pension and funds from a retirement plan. He enjoys eating Cuban and Italian food. He especially enjoys eating hamburgers. He takes multivitamins but does not take oral supplements. His wife would like you to consider inserting a PEG tube. She saw a neighbor who had one placed and lived for a long time.



of 193

Physical Examination: Mr. Berg is alert and in no distress. He has temporal wasting and appears cachectic. He is oriented to name only. His blood pressure is 117/68 mm Hg and pulse 82 supine with no changes noted upon standing. He is edentulous. His thyroid gland is not palpable. Lungs are clear. There is a grade II/VI systolic ejection murmur heard at the base without radiation. Abdomen is nontender and no masses are felt. Rectal examination is normal, and stool is guaiac negative. He has 1+ pedal edema. No focal neurological deficits are noted. MMSE 7/30.


Diagnostic Testing: CBC reveals hematocrit of 34 and lymphocyte count of 700 (low). Albumin is 2.4, ESR is 38, cholesterol is 100, prealbumin is 10, and TSH is 3. Chest and abdominal X-rays are normal. An MRI of the brain reveals cerebral atrophy and 2 old lacunar infarcts.



of 193

PMP SCORING SHEET

Checklist: Malnutrition Station 18

Please write each item in the history, physical exam, diagnostic testing, diagnosis and treatment in the space provided. HISTORY Done Not Done 1. Amount of weight loss/period 2. Appetite 3. Duration of anorexia 4. Food preferences 5. Nausea or vomiting 6. Rectal bleeding 7. Medications 8. Dysphagia 9. Painful mastication 10. Odynophagia 11. Abdominal pain 12. Mood 13. Constipation-change in bowel habits 14. Dietary supplements 15. Income and benefits. 16. Meal arrangement: wife able to cook? Meals-on-Wheels? 17. Alcohol 18. Medications recently introduced 19. ADLs 20. Cognitive symptoms 21. Behavioral symptoms 22. Advance Care planning PHYSICAL EXAM Done Not Done 1. Vital signs 2. Orthostatics 3. Temporal wasting 4. Assess for condition of teeth/dentures 5. Lymphadenopathy 6. Cardiovascular-respiratory 7. Abdomen 8. Edema 9. Hair pluckability 10. Weight 11. Depression screen 12. Dementia screen – MMSE, CDR, GDS/FAST (advanced dementia) 13. Rectal exam


of 193

DIAGNOSTIC TESTING Done Not Done 1. CBC, diff- lymphopenia 2. BUN/creatinine 3. Albumin 4. Prealbumin 5. ESR 6. Abdominal X-ray 7. Thyroid function tests 8. Chest X-ray 9. Cholesterol 10. Calorie count DIAGNOSIS Done Not Done 1. MEDICAL: Weight loss-poor oral intake 2. MEDICAL: Hypertension 3. FUNCTIONAL: Self-care deficit 4. PSYCHOLOGICAL: Alzheimer’s disease-severe 5. PSYCHOLOGICAL: Possible depression 6. SOCIAL: Advance Care Planning 7. SOCIAL: Caregiver burden TREATMENT (MANAGEMENT) Mention whether medical, functional, psychological or social-spiritual

Done Not Done

1. MEDICAL: Educate about PEG in severe AD 2. MEDICAL: Loosen dietary restrictions 3. MEDICAL: Encourage patient to eat foods he likes 4. MEDICAL: Dental evaluation 5. MEDICAL: Nutritional supplements 6. MEDICAL: Testosterone replacement 7. MEDICAL: Marinol (dronabinol) – caution about side effects (sedation,

hallucinations, dizziness)

8. MEDICAL: Change to different blood pressure medication 9. MEDICAL: megesterol acetate contraindicated due to history of DVT 10. FUNCTIONAL: Consider home health aide 11. FUNCTIONAL: Exercise program 12. PSYCHOLOGICAL: Treatment for depression - mirtazapine 13. SOCIAL: Senior center or day care to socialize 14. SOCIAL: Formal and informal assistance from community, church, etc. COMMENTS


of 193

Fellow:



of 193

Station 19: Pressure Ulcers Issue Assessing and managing patients with pressure ulcers Presenting Situation A patient who fell at home and remained on the ground for several hours develops a pressure ulcer while in the hospital. Activity Computer-based patient management problems (Clinical vignettes) Time Required 20 minutes This station was developed by Jorge Ruiz, MD


of 193


Brief Case Introduction: Mr. Julius Thompson is a 73-year-old male who is brought into the emergency room by ambulance after his daughter found him at home lying on the floor, unconscious. He is admitted to the medicine service with diagnoses of pneumonia, a fall with a long lie, dehydration, and altered mental status. By the second hospital day, he has develops a new pressure ulcer over the right lateral malleolus. You are called to assist the medical residents with the management of the pressure ulcer.



of 193

SCREEN 3 History: In this portion of the vignette, you have to answer the previous three questions using a narrative format. You can add additional history if you wish. PLEASE CONTINUE READING THE VIGNETTE AND ANSWER THE QUESTION BELOW. DO NOT MOVE AHEAD UNTIL YOU HAVE ENTERED YOUR ANSWERS. Mr. Thompson has diabetes complicated by neuropathy, retinopathy, and gastroparesis, hypertension, hyperlipidemia, cerebrovascular accident 18 months ago, and obesity. He was diagnosed with depression following his stroke, and he was treated for 6 months with sertraline with improvement. The medication was discontinued. His other medications include 70/30 insulin twice a day, lisinopril, simvastatin, aspirin, metoclopramide before meals and at bedtime. He has a 54-pack-year smoking history (quit 2 years ago). Prior to admission, he required assistance with bathing but was otherwise independent. He ambulated with a rolling walker. A home health aide provided assistance with bathing and light housework, and the daughter visited almost every day. He had a good appetite before admission but in the hospital he does not feel like eating much. Currently, he is dependent for most ADLs, requiring assistance with bathing, toileting, and grooming. He can feed himself but needs someone to set up the tray. He can ambulate with a walker and one-person assist. He is continent of stool and urine. He has not completed advance directives.



of 193

Physical Examination: Vital signs BP 150/85, HR 68, RR 15, afebrile, pain level 5/10 (ulcer site). Weight: 180 lbs (down from 200 lbs 3 months ago). Lungs: clear to auscultation. Cardiovascular: regular rhythm and rate, occasional ectopic beats, no murmurs. Abdomen: soft, non-tender, normal bowel sounds, no visceromegaly. Skin: round, 5 cm black eschar on right malleolus that is debrided to an ulcer that extends through the dermis into the fascia, which is intact, there is small amount of clear exudate, no tunneling. There is also non-blanchable erythema in the sacral area and a 2 cm blister on the right ankle. Pulses: dorsalis pedis and posterior tibialis are normal bilaterally. Neurological: alert, oriented to person and place, disoriented to time. Muscle strength 5/5 left side, 3/5 on the right upper extremity and 4/5 right lower extremity. Cranial nerves, sensory and cerebellar signs were normal. Rectal: normotonic sphincter, no masses, small amount of soft stool, guaiac negative. MMSE 26/30 (missed the date, day of the week, month). GDS 4/15.


Diagnostic Testing: CBC shows 8000 WBCs with lymphopenia, hematocrit 34, platelets 300,000, MCV 88. BMP is normal with exception of glucose of 210. Hemoglobin A1c is 7.5, albumin is 2.0, cholesterol is 100, TSH is 2.0. Foot X-rays are negative for osteomyelitis. UA shows 5-10 WBCs, no bacteria. Calorie count indicates <50% meals over three days.



of 193

PMP SCORING SHEET

Checklist: Pressure Ulcers Station 19

Please write each item in the history, physical exam, diagnostic testing, diagnosis and treatment in the space provided. HISTORY Done Not Done 1. Pain level 2. Mobility 3. History of pressure ulcers 4. ADLs before hospitalization 5. ADLs during hospitalization 6. IADLs before hospitalization 7. IADLs during hospitalization 8. Oral intake-anorexia before hospitalization 9. Oral intake-anorexia during hospitalization 10. Cognitive impairment 11. Urinary incontinence 12. Fecal incontinence-constipation 13. Mood 14. Medications 15. Weight loss 16. Diabetes mellitus 17. Stroke 18. Falls 19. Living situation-caregiver 20. Fever or other signs of infection 21. Alcohol PHYSICAL EXAM Done Not Done 1. Vital signs 2. Skin exam 3. Weight 4. Cardiovascular 5. Abdomen 6. Rectal 7. Musculoskeletal 8. Pulses 9. Neurological 10. MMSE 11. GDS


of 193

DIAGNOSTIC TESTING Done Not Done 1. CBC 2. BMP 3. Liver function tests-albumin 4. Cholesterol 5. TSH 6. Foot X rays 7. Pre-albumin 8. Calorie count DIAGNOSIS Done Not Done 1. MEDICAL: Uncontrolled diabetes mellitus type 2, neuropathy, gastropathy 2. MEDICAL: Previous stroke 3. MEDICAL: Malnutrition 4. MEDICAL: Pain 5. FUNCTIONAL: Pressure ulcer stage 3 right malleolus 6. FUNCTIONAL: Pressure ulcer stage 2 right ankle 7. FUNCTIONAL: Pressure ulcer stage 1 sacrum 8. FUNCTIONAL: Impaired mobility 9. FUNCTIONAL: Self-care deficit 10. PSYCHOLOGICAL: Possible cognitive impairment 11. SOCIAL: Advance care planning TREATMENT (MANAGEMENT) Mention whether medical, functional, psychological or social-spiritual

Done Not Done

1. MEDICAL: Increase insulin 2. MEDICAL: Oral nutritional supplements, consider PEG, dietetics consult 3. MEDICAL: Consult surgery for debridement 4. MEDICAL: Analgesics-tramadol or combination opioids 5. FUNCTIONAL: Pressure relief- special mattress or bed 6. FUNCTIONAL: Pressure relief- turn Q2hours 7. FUNCTIONAL: Pressure ulcer stage 3 right malleolus – hydrocholoid

dressings Q3 days

8. FUNCTIONAL: Pressure ulcer stage 2: Right ankle - hydrocholoid dressings or tegaderm

9. FUNCTIONAL: Pressure ulcer stage 1 - hydrocholoid dressings or tegaderm

10. FUNCTIONAL: Bedside commode - condom catheter 11. FUNCTIONAL: Physical therapy - increase activity 12. FUNCTIONAL: Occupational therapy - increase activity 13. PSYCHOLOGICAL: Dementia work up? COMMENTS


of 193

Fellow:



of 193

Station 20: Insomnia Issue Assessing and managing patients with insomnia Presenting Situation A patient presents to the outpatient clinic with difficulty sleeping. Activity Computer-based patient management problems (Clinical vignettes) Time Required 20 minutes This station was developed by Regina Marranzini, MD Paul Cherniack, MD


of 193


Brief Case Introduction: Mrs. Joan Armitage is a 78-year-old female who presents to your outpatient clinic with difficulty sleeping.

Questions: Choose the appropriate range of questions in your opinion. Remember, these are the most important questions. PLEASE READ ALL THREE QUESTIONS, THEN ANSWER UNDER THE MOST SUITABLE HEADING BELOW. DO NOT MOVE AHEAD UNTIL YOU HAVE ENTERED YOUR ANSWERS. Question: History of Present Illness What are the 7 (Range 5-7) to 12 (Range 8-12) most important questions you want to ask this patient about his/her symptoms? Question: Past Medical History What are the 4 (Range 3-5) to 7 (Range 6-9) most important questions you want to know about his/her past medical history? Question: Social-Family History What are the 3 (Range 3-5) to 6 (Range 6-9) most important questions you want to know about him/her as a person (his social history and other relevant issues)? SCREEN 3 History: In this portion of the vignette, you have to answer the previous three questions using a narrative format. You can add additional history if you wish. PLEASE CONTINUE READING THE VIGNETTE AND ANSWER THE QUESTION BELOW. DO NOT MOVE AHEAD UNTIL YOU HAVE ENTERED YOUR ANSWERS.


of 193

She has been having trouble sleeping for months. She is often unable to fall asleep and sometimes wakes up in the middle of the night. She denies orthopnea or paroxysmal nocturnal dyspnea. Mrs. Armitage wakes up about fours times a night to urinate. She does not endorse morning headaches. She is being treated for congestive heart failure (CHF), hypothyroidism, atrial fibrillation, osteoarthritis, diabetes, and hypertension. She takes warfarin, atenolol, ramipril, and L- thyroxine, all in the morning. She takes acetaminophen as needed, furosemide and metformin twice a day (in the morning and at bedtime) and temazepam at bedtime. You are now her new doctor. You practice in a busy medical clinic at a large metropolitan hospital. The clinic clerk brings to you three thick binders containing old medical records. The patient is accompanied by her live-in home attendant. The attendant has not noticed any loud snoring or any leg movements at night. The patient admits to shortness of breath, fatigue, and difficulty sleeping. She is alert and able to tell you her medication regimen correctly. She reports depressed mood that she attributes to "all of her medical problems." She takes frequent naps during the day. Her pain level is on average 5/10, 7/10 at its worst, and 4/10 after acetaminophen. She goes to bed around 7 pm and usually wakes up at 2 am. She goes to bed early because she has nothing else to do at home. She tells you that most of her friends are dead and that it is difficult for her to go out at night. She feels isolated. Her arthritis prevents her from doing needle work. Her vision is poor, so she has a lot of trouble reading. She used to enjoy watching television but she states that she no longer feels enjoyment doing so.



of 193

Physical Examination: Her blood pressure is 130/90 with no orthostatic changes, pulse is 60 and irregular. She is afebrile and her respiratory rate is 14. She is mildly obese. Eyes: mild cataracts, poor visual acuity. Neck: supple, no bruits, thin and non tender. Throat: no signs of obstruction. Pulmonary: bibasilar rales. Cardiovascular: irregularly irregular rhythm, holosystolic murmur at the left sternal border, audible valve click, genu varum, and 2+ pitting edema of her lower legs. Musculoskeletal: no inflammatory signs in large joints. Rectal: small amount of soft stool, guaiac negative. Neurological: alert, oriented to person, place, and time. Muscle strength, cranial nerves, coordination and sensory exam are normal. No tremors. Gait is normal. MMSE 29/30 and GDS 6/15.


Diagnostic Testing: CBC and BMP are normal. Glucose is 108. BNP is 103. Chest X-ray shows mild cardiomegaly but no pulmonary congestion.



of 193

PMP SCORING SHEET

Checklist: Insomnia Station 20

Please write each item in the history, physical exam, diagnostic testing, diagnosis and treatment in the space provided. HISTORY Done Not Done 1. Sleep patterns 2. Time in bed. Actual time sleeping 3. Problem initiating or maintaining sleep 4. Sleeping during the day: naps 5. Longstanding history of insomnia 6. Alcohol intake 7. Over the counter medications 8. Medications 9. Caffeine intake 10. Pain at night 11. Eating or drinking late at night 12. Nocturia 13. Leg movements 14. Snoring 15. Exercise 16. Mood 17. Impact on social activities 18. Impact on function (ADLs-IADLs) 19. Constipation 20. Duration of insomnia 21. Life stressors 22. Support systems- formal and informal 23. Multiple awakenings 24. Morning headaches PHYSICAL EXAM Done Not Done 1. Vital signs 2. Gait exam 3. Cardiovascular exam- assessing for fluid overload (lungs, pedal edema) 4. Pulmonary exam 5. Neck and throat exam 6. Vision 7. Neurological exam 8. Musculoskeletal 9. Depression screen 10. MMSE


of 193

DIAGNOSTIC TESTING Done Not Done 1. CBC 2. BMP 3. Sleep questionnaires/ sleep logs 4. Chest X rays 5. EKG DIAGNOSIS Done Not Done 1. MEDICAL: Insomnia (chronic type) multifactorial 2. MEDICAL: Osteoarthritis 3. MEDICAL: Atrial fibrillation-anticoagulation 4. FUNCTIONAL: Vision impairment 5. FUNCTIONAL: Polypharmacy 6. FUNCTIONAL: Fall risk 7. PSYCHOLOGICAL: Depression 8. SOCIAL: Isolation 9. SOCIAL: Advance care planning TREATMENT (MANAGEMENT) Mention whether medical, functional, psychological or social-spiritual

Done Not Done

1. MEDICAL: Pain control – tramadol or combination opioids 2. MEDICAL: Start slow taper/titrating down of temazepam 3. MEDICAL: Reduce or discontinue diuretics-change bedtime dose 4. MEDICAL: Sleep hygiene measures 5. FUNCTIONAL: Visual aids 6. FUNCTIONAL: Home safety evaluation 7. FUNCTIONAL: Exercise/activity program 8. PSYCHOLOGICAL: Antidepressants or psychology/psychiatry consult 9. SOCIAL: Involve in social activities –volunteers or adult day care COMMENTS


of 193

Fellow:



of 193

Station 21: Urinary Incontinence Issue Assessing and managing patients with urinary incontinence Presenting Situation A patient presents to the outpatient clinic with worsening urinary incontinence since her recent hospitalization. Activity Computer-based patient management problems (Clinical vignettes) Time Required 20 minutes This station was developed by Renuka Tunuguntla, MD Jorge Ruiz, MD


of 193


Brief Case Introduction: Mrs. Lisa Albright, a 75-year-old woman with history of hypertension, osteoarthritis of both knees & obesity, fell and fractured her right shoulder in the middle of the night while trying to get to the bathroom. She was admitted to the hospital where she underwent right shoulder surgery. After discharge, she comes to your office for follow up. Mrs. Albright is very concerned about worsening urinary incontinence and demands that you help her with this problem.



of 193

SCREEN 3 History: In this portion of the vignette, you have to answer the previous three questions using a narrative format. You can add additional history if you wish. PLEASE CONTINUE READING THE VIGNETTE AND ANSWER THE QUESTION BELOW. DO NOT MOVE AHEAD UNTIL YOU HAVE ENTERED YOUR ANSWERS. Mrs. Albright has been under your care for several years and has been treated for hypertension, osteoarthritis of both knees, and obesity. She had a stroke 4 years ago but the neurological deficits resolved. She has no history of diabetes or glaucoma. Her hypertension had been well controlled with hydrochlorothiazide 25 mg twice a day and atenonol 50 mg daily. Because she does not tolerate nonsteroidal anti-inflammatory agents, she takes acetaminophen 1-2 times daily for her knee pain but still has pain when she walks and sometimes uses a cane. Other medications include enteric-coated aspirin and a multivitamin. Mrs. Albright explains that on the night of the fracture, she woke up to urinate around midnight and fell and broke her shoulder. She related her fall to drinking wine that night with a friend, which made her a little more drowsy than usual when she got up at midnight. She drinks alcohol only occasionally and has not had trouble before. The conversation reminds Mrs. Albright that she experienced frequent nocturnal urination during hospitalization and on several occasions was unable to get to the toilet on time and became incontinent. When questioned, she admits that she has had urinary frequency for several years but managed it by avoiding beverages before sleep or before leaving her house. She also avoids going out for long periods during the day, and whenever she returns from her brief excursions, she develops urinary urgency "as soon as the key goes into the lock." She has occasionally experienced leakage when sneezing, standing, or coughing, but this most commonly occurs when she is trying to hold her urine during one of her "urgent" episodes. Still, she did not view her urinary pattern as a big problem until her recent hospitalization. She denies any problems with memory and is independent for her ADLs and most of her IADLs. She gets some help for housekeeping because of her arthritis. She has had 3 uncomplicated vaginal deliveries. She has 3 sons. No advance directives.

Question: Physical Examination What are the 4 (Range 3-5) to 6 (Range 6-9) most important elements of the physical examination that need to be performed on this patient? (Please be very specific: for example, do not say you would “examine the knee”, but say what you would look for when you examined the knee, for example: “examine the knee for redness, swelling, point tenderness”).


of 193

SCREEN 4 Physical Examination: In this portion of the vignette, you present the physical findings. Be certain to include those that the fellow should have requested. Remember, these are the most important elements of the physical examination and should be presented in a narrative format. PLEASE CONTINUE READING THE VIGNETTE AND ANSWER THE QUESTION BELOW. DO NOT MOVE AHEAD UNTIL YOU HAVE ENTERED YOUR ANSWERS.

Physical Examination: In general, she is in no acute distress. Vitals are stable with pulse of 60, BP 136/72 without orthostatic changes. Pain is 3-4/10 on average with highest 7 and lowest 2. HEENT exam is normal. Neck is supple without JVD. Chest is clear with no adventitious sounds. Cardiovascular exam is unremarkable with normal heart sounds and no murmurs or gallops. She does not have any pedal edema. Abdomen is soft, non-tender, normal bowel sounds, no masses or hepatosplenomegaly. She is awake and oriented x 3. Cranial nerves are normal. There is no sensory impairment. Strength is 5/5 in all 4 limbs; deep tendon reflexes are 2+ with down going toes. She ambulates with a walker. Pelvic examination reveals healthy vaginal mucosa without signs of inflammation, no cystocele, rectocele, or uterine prolapse. Tone is normal at rest but reduced on squeezing. Rectal tone is normal with soft, guaiac negative stool. MMSE 30/30; GDS 2/15.


Diagnostic Testing: Stress test is positive, voided volume is 150 mL with a postvoid residual volume of 40mL. Urinalysis is unremarkable as are electrolytes and calcium.



of 193

PMP SCORING SHEET

Checklist: Urinary Incontinence Station 21

Please write each item in the history, physical exam, diagnostic testing, diagnosis and treatment in the space provided. HISTORY Done Not Done 1. Duration of Incontinence- acute vs. chronic 2. Urgency 3. Frequency 4. Nocturia 5. Pads or diapers-quantity 6. Constipation 7. Incontinence associated with activity, cough or laughing 8. Severity 9. Activities of daily living 10. Instrumental Activities of daily living 11. Pain 12. Sleep pattern 13. Treatment for UI before and if so what was it and did she respond 14. Medications (including OTC meds) 15. History of frequent UTIs 16. History of diabetes mellitus 17. History of stroke 18. Memory problems 19. Visual impairment (especially h/o glaucoma in view of treatment which is

with anticholinergic medications)

20. Alcohol intake 21. Caffeine intake 22. Fluid intake 23. Number of children and vaginal deliveries 24. Incontinence affecting social life 25. Mood 26. Economic burden if she is using diapers PHYSICAL EXAM Done Not Done 1. Vital signs 2. Orthostatics 3. Cardiovascular and fluid status including pedal edema 4. Respiratory 5. Abdomen 6. Neurological 7. Pelvic exam 8. Rectal exam- tone and impaction 9. MMSE 10. GDS


of 193

DIAGNOSTIC TESTING Done Not Done 1. CBC 2. BMP 3. Calcium 4. Cough test 5. Voided volume 6. UA by dipstick for infection 7. Post-void residual DIAGNOSIS Done Not Done 1. MEDICAL: Osteoarthritis 2. MEDICAL: Constipation 3. FUNCTIONAL: Polypharmacy 4. FUNCTIONAL: Falls 5. FUNCTIONAL: Urinary incontinence: etiology multifactorial 6. FUNCTIONAL: Mixed urge and stress incontinence 7. SOCIAL: advance care planning TREATMENT (MANAGEMENT) Mention whether medical, functional, psychological or social-spiritual

Done Not Done

1. MEDICAL: Analgesics for OA 2. MEDICAL: Laxatives for constipation 3. FUNCTIONAL: Discontinue thiazide or at least reduce the dose and give

some other medication for hypertension such as enalapril

4. FUNCTIONAL: Bladder diary 5. FUNCTIONAL: Bladder training and pelvic floor muscle exercises 6. FUNCTIONAL: Consider trial of anticholinergic agents 7. FUNCTIONAL: Fall prevention program 8. FUNCTIONAL: Home safety assessment 9. FUNCTIONAL: Bedside commode COMMENTS


of 193

Fellow:



of 193

Station 22: Polypharmacy Issue Manage patients with polypharmacy Presenting Situation A patient with multiple co-morbidities and medications presents to the outpatient clinic. NOTE: This case is presented in a different format. The task of performing a full medication review does not lend itself to the evolving case scenario used in other stations. Activity Computer-based patient management problems (Clinical vignettes) Time Required 20 minutes This station was developed by Anita Bagri, MD Adam Golden, MD


of 193

SCREEN 1 INSTRUCTIONS: You have been given a clinical vignette that takes approximately 20 minutes to complete. Please read the clinical material and answer the question below. SCREEN 2 PLEASE CONTINUE READING THE VIGNETTE BELOW AND ANSWER THE QUESTION THAT FOLLOWS. History: In this portion of the vignette, you present the case. History: Mr. Phil Roscoe is a 70-year-old male who comes in for a routine office visit. He was last seen one year ago. He reports "trouble breathing" for the past few days but otherwise feels well. His symptoms are most noticeable with exertion and improve with rest. He cannot walk as far as normal without feeling short of breath. Lying flat makes him feel like he is suffocating. His legs are swollen, but he is still able to wear his shoes. He denies chest pain, paroxysmal nocturnal dyspnea, lightheadedness, palpitations, cough, or claudication. He was last hospitalized two years ago for similar symptoms. The remainder of the review of systems is negative. PMH: hypertension, diabetes mellitus type 2, atrial fibrillation, congestive heart failure, hyperlipidemia, and osteoarthritis. Social history: He lives alone since his wife's death last year. His daughter is nearby and visits him twice a month. He drinks anywhere from 2-6 beers a night with his friends and smokes 1/2 pack per day. Functional Status: He is independent with all activities of daily living and instrumental activities of daily living. He continues to drive without accidents, getting lost, or traffic violations. He tries to take his medications as prescribed but admits to skipping some doses. He has run out of some of them but is not able to tell you which ones. He is not sure why he must take so many pills and feels they are not helping him. Below is the list of medications he brings to the office: captopril 10mg oral tid pioglitazone 15mg oral daily metformin 1000mg oral bid simvastatin 80mg oral at bedtime rosiglitazone 4mg oral bid warfarin as directed to keep INR between 2-3 temazepam 30mg at bedtime


of 193

atenolol 25mg oral daily glyburide 10mg oral bid diltiazem 240mg oral daily potassium chloride 20mEq oral daily furosemide 40mg oral daily digoxin 250mcg oral daily propoxyphene/acetaminophen 10/650, 1 tablet oral q8h prn zolpidem 10mg oral at bedtime In addition to the above, he takes an over the counter sleeping pill and ibuprofen three times a day for knee pain. He takes saw palmetto because a friend recommended it to him. Physical exam: weight 195 lbs (baseline 185 lbs) afebrile RR 16 O2 sat 95% on room air Supine BP 160/90 HR 85 Standing BP 155/85 HR 85 General: elderly male, appears his stated age, ambulates unassisted but is short of breath after walking from waiting room to exam room, after 2 minutes of rest, he is able to speak in full sentences Neck: elevated JVP CV: laterally displaced PMI, irregularly irregular, no m/g/r, no S3 gallop Lungs: symmetric expansion, no use of accessory muscles, bibasilar rales, no wheezes Abdomen: benign Rectal: normal tone, normal prostate, guaiac negative brown stool Extremities: 2+ bilateral lower extremity edema up to knees Neurological: Alert, oriented times 3. Muscle strength and tone are normal. No sensory abnormalities. Cranial nerves intact. Laboratory data: Na 140, K 5.5, Cl 100, HCO3 22, BUN 21, Cr 1.4, glucose 214 (CrCl 58 cc/min)total protein 7.8, albumin 3.8, AST 154, ALT 186, total bilirubin 0.9, alk phos 45 HgA1c 8.1% INR 1.8 Digoxin level 2.1 (normal range 0.8 to 2.0 ng/ml) Total cholesterol 195, triglycerides 90, HDL 35, LDL 150 PLEASE CONDUCT A COMPLETE MEDICATION REVIEW. What would your plan be, including your recommendations to the patient? Please be VERY specific.


of 193

PMP SCORING SHEET

Checklist: Polypharmacy Station 22

Please write each item in the history, physical exam, diagnostic testing, diagnosis and treatment in the space provided. HISTORY Done Not Done 1. Ask about medication adherence 2. Investigate possible causes of non-adherence 3. Patient education

a. Lifestyle modification (diet, exercise) b. Involvement in own care (daily weights, fingersticks) c. Importance of medication adherence (indications for each

medication, possible complications of non-adherence)

d. Discuss decreasing alcohol consumption (to <2 drinks/day) e. Discuss smoking cessation f. Use of over-the-counter medications (side effects of NSAIDs, sleeping

pills)

g. Importance of monitoring and diet with certain medications (warfarin) h. Alcohol use with benzodiazepines i. Importance of bringing pill bottles to each visit

4. Discontinue one of the thiazolidinediones (duplicate class) 5. Discontinue potassium supplementation (hyperkalemia) 6. Discontinue statin (elevated AST/ALT) 7. Replace propoxyphene with alternative pain medication 8. Consider discontinuing saw palmetto (normal prostate on exam) 9. Taper and discontinue benzodiazepine (side effect profile, already taking

med for sleep)

10. Investigate OTC sleeping agent (discontinue if diphenhydramine) 11. Decrease dose or discontinue digoxin (supratherapeutic level, already on

AV nodal agents for heart rate control)

12. Decrease dose of zolpidem (5mg recommended in elderly) 13. Change to once daily ACE inhibitor (improve adherence) or discontinue

ACE inhibitor (hyperkalemia)

14. Increase furosemide to bid dosing (for CHF exacerbation) or admit for intravenous administration

15. No change or increase warfarin dose (with plan to check INR) 16. Streamline BP regimen (may discontinue CCB and monitor) 17. Streamline DM regimen (may discuss insulin) 18. Schedule regular follow-up 19. Consider home health for BP and glucose monitoring 20. Recommend pill box for medication management COMMENTS


of 193

Fellow:



facilitator’s manual - aamc … · fellowship osce facilitator’s manual. miami, florida:...

Documents