By Tim Webster(originally published in December 2011)
As the field of simulation grows and develops, so too must the tools of the trade grow and develop along with it. One the tools we’re using at the University of Manitoba is the “Case Note Template,” which we are finding not only makes it easier for course instructors and faculty to create scenarios, but also for SPs to learn them. What follows is an example of the kind of clarity we’d like to introduce to even the most complex of cases, one that we’ve found particularly pertinent to sessions scheduled during the holiday season. This is only a potential case, so no confidentiality was breached in sharing this with our readers.
Standardized Patient Program
University of Manitoba
Case Name / Number: 101225XMAS
Edited by Tim Webster, December 2010
Type of session (check one): X Teaching
Type of station (check all that apply): X Communication X Physical Exam
Focus of case: Aerial Sleigh-Borne Present-Deliverer’s Syndrome
Allotted time for completion: 20 minutes
Task(s) to be completed:
__ obtain a complete medical history
X obtain focused and relevant history
__ deal with a communication issue
__ deal with an ethical issue
__ perform a complete physical exam
X perform a focused physical exam
X provide patient education
__ provide student education
__ counsel the patient
X indicate management decisions to be made
__ discuss monitoring plan
__ indicate how follow-up will occur
- Type of encounter (e.g new patient, E.R., clinic): new patient
- Location / Setting of encounter: physician’s office
- Opening statement from SP: “Ho! Ho! Ho!”
- Name: S. Claus
- Age: must appear to be over 65
- Gender: male
- Ethnic background: Caucasian
- Marital Status: married
- Weight (if relevant): BMI of 30 or greater
- Highest level of education: unknown
- Occupation: delivering presents once a year, on December 25th, to many people worldwide. He flies in a sleigh pulled by eight tiny reindeer, and gains access to homes via chimneys. He has performed this work for as long as he can remember.
- Primary language: English
- Family members (if relevant): wife, Mrs. Claus
- Chief complaint (today): 1) generalized aches and pains, 2) sore red eyes, 3) depression, and 4) shortness of breath
- History of present illness:
1) Patient Claus has extensive ecchymoses (bruises), abrasions, lacerations, and first-degree burns on his head, arms, legs, and back.
He has leukoderma (loss of pigmentation) and anesthesia on his nose, cheeks, groin, and fingers
He has headaches nearly every day, usually starting half way through the day.
He has experienced chronic back pain for several years.
2) His conjunctivae (clear membranes of the eyes) are hyperalgesic (sensitive to pain) and erythematous (reddened)
3) Patient Claus’ depression has been chronic for several years.
4) He has had shortness of breath for several years.
1) His bruises, abrasions, lacerations, and first-degree burns were caused and are worsened by: repeated chimney descents, falls from his sleigh, collisions with birds during his flights, gunshot wounds (while flying over the Los Angles area), and bites consistent with reindeer teeth.
The loss of pigment and sensation on his face and in his fingers and groin are consistent with frostbite caused by periods of hypothermia during high-speed, high-altitude flights.
His headaches get worse with stress.
The back pain gets worse when carrying a heavy sack of toys, enduring bumpy sleigh rides, and falling feet-first to the bottom of chimneys.
2) Patient Claus’ sore eyes are aggravated by the dust, debris, and other particles which strike his eyes at high velocity during his flights.
3) Because he experiences total darkness lasting many months during winter at the North Pole, Seasonal Affective Disorder (SAD) may contribute to his depression.
4) His shortness of breath worsens during exertion.
- Past medical history:
Immunizations: All his immunizations are up-to-date, including all available vaccines for tropical diseases.
Diet & Exercise: He does not exercise.
He eats large meals with high sugar and cholesterol levels, and a high percentage of calories derived from fat. He subsists all year on food he collects on December 25, which consists mainly of eggnog, soft drinks, and cookies.
Alcohol & Tobacco: Patient Claus only admits to drinking once a year: “Only when someone spikes the eggnog. Ho! Ho! Ho!”
He has smoked pipe tobacco for many years, although workplace regulations at the North Pole have forced him to cut back to one or two pipes per day for the last 5 years.
- Relevant social history: His travel history is extensive, as he visits nearly every location in the world annually.
- Initial posture: seated on side of examination table
- Appearance: rosy cheeks, nose, & eyes; full, white beard with nicotine stains; rapid, shallow breathing
- Dress: fur-trimmed red suit with matching cap, black boots, glasses
- Attitude / agenda: Although his demeanor is jolly, Patient Claus is concerned about his symptoms and thought he should have them checked out: “I’m not as young as I used to be! Ho! Ho! Ho!
- Mannerisms / non-verbal gestures: When he laughs, Patient Claus’ belly will jiggle like a bowlful of jelly.
- Physical symptoms or findings:
Patient Claus is in mild respiratory distress.
A neurological examination will reveal a mild herniation of his L4-L5 or L5-S1 disk, and loss of sensation in the tip of the nose, cheeks, and fingers.
If the interviewer initiates an eye exam, Patient Claus will say “The results of that test over there. Ho! Ho! Ho!” (The sheet will reveal numerous randomly occurring corneal abrasions and 20/80 vision).
- Psychological symptoms or findings:
Patient Claus has a number of unresolved issues in his personal and professional life which cause him distress.
He exhibits long-term amnesia, and cannot recall any events more than 5 years ago. This may be due to a repressed psychological trauma he experienced, head trauma, or, more likely, the mythical nature of his existence.
Although he has a jolly demeanor, he expresses profound unhappiness.
He reports anger at not receiving royalties for the widespread commercial use of his likeness and name.
The patient feels annoyed and worried when he is told many people do not believe he exists.
He reports great stress over having to choose which gifts to give to children, and a feeling of guilt and inadequacy over the decisions he makes as to which children are “naughty” and “nice”.
- Defining statements: “Ho! Ho! Ho!”
- Any specific questions or statements the patient MAY make?
“Have you been a good boy / girl this year?” (dependent on the interviewer’s gender)
“What do you want for Christmas?”
- Any specific questions or statements the patient MUST make?
If the interviewer refers Patient Claus to a physiotherapist regarding his back pain, he will agree.
If the interviewer refers Patient Claus to a psychiatrist (or other mental health professional), he will agree.
If the interviewer suggests that Patient Claus consider switching to a closed-canopy, heated, pressurized sleigh, he is reluctant: “I’ll have to think about it.”
If the interviewer suggests that Patient Claus switch to a high-fibre, low cholesterol diet, he may agree, depending on the rapport the interviewer has built. If he does not trust the interviewer sufficiently (“I’m not sure –after all, you’re on the naughty list!”), he will refuse.
If the interviewer suggests that Patient Claus reduce his smoking and drinking, he may agree, depending on the rapport the interviewer has built. If he does not trust the interviewer sufficiently (“I’m not sure –after all, you’re on the naughty list!”), he will refuse.
If the interviewer suggests that Patient Claus add a helmet and protective accessories to his uniform, he will refuse.
If the interviewer indicates that s/he wishes to perform a rectal exam, Patient Claus will say “The results of that test over there. Ho! Ho! Ho!”
- corn cob pipe
- a sheet indicating vital signs
- a sheet indicating results of Fluorescein staining (eye exam)
- a sheet indicating the results of a rectal exam
Reward a “good interviewing performance.”
If you, as the SP, perceive the interviewer asking open-ended questions and seeking to be helpful in an appropriate manner, Patient Claus should provide information more readily and at least agree to consider some of the options/suggestions they suggest. If the interviewer has gained his trust, he will share his concerns and thoughts about the situation.
The SP does not need to memorize the following information; it is provided only to clarify questions about Patient Claus’ medical history and symptoms:
Patient Claus has no evidence of acute cardiac or pulmonary failure, but he is quite unfit due to his mainly sedentary lifestyle and poor eating habits which, along with his stress, smoking, and male gender, place him at high risk for coronary heart disease, myocardial infarction, emphysema and other problems.
Subsequently blood tests (revealed in the PEP) show higher-than-normal CO levels, caused by smoke inhalation during chimney descent into non-extinguished fireplaces.
Instructions to candidate:
You are about to meet Mr. S. Claus, of indeterminate age, who presented to your family practice office with complaints of generalized aches and pains, sore red eyes, depression, and general malaise.
He has a blood pressure of 150/95, a heart rate of 90 beats/minute, and a respiratory rate of 40.
The patient wears corrective lenses, and has 20/80 vision.
You are to:
1) conduct a focused medical history;
2) perform a focused physical examination;
3) advise the patient.
You have twenty (20) minutes.