Standardized Patient Program (SP Program)

Presenting Complaint: painful knee

Actual Diagnosis: osteoarthritis

Patient demographics:

Age: 65

Sex: female

Race: does not matter

Body habitus: does not matter

Case summary: Eugenia Frankel is a 65 year old woman who comes to the clinic because of knee pain. She has had progressively worsening pain in the right knee over the past five years. The pain is now almost daily and has begun to interfere with her ability to perform her daily activities.

SCRIPT TRACKING

Case Author : KS/MAA

Date of Development: May 2002

Most recent update: May 2003

(case retired from assessment case pool Sept 2004)

CASE OBJECTIVES: (samples)

(1) Evaluate chronic joint pain in a geriatric patient

(2) Address both the medical and lifestyle issues associated with decreased mobility in an active older person

CASE SUMMARY

You are portraying Eugenia Frankel, a 65 year old woman who comes to the clinic because of knee pain. You have had progressively worsening pain in your right knee over the past five years. The pain is now almost daily and has begun to interfere with your ability to perform you daily activities.

CASE SETTING:

The student must perform a focused medical interview and a focused physical examination

HOW YOU APPEAR DURING THE ENCOUNTER

Physical Description

Dress: You will be dressed in a hospital gown. Please wear boxer shorts under your gown so that the student can easily examine your legs without compromising your modesty.

Description of Affect and Behavior:

You are pleasant and cooperative with the interviewer. You are an easygoing person and generally enjoy interacting with other people. You are concerned about your knee and you are uncomfortable which will influence your behavior a little. You should maintain normal levels of eye contact with the student.
WHY YOU ARE SEEING THE DOCTOR TODAY

Opening statement

The student may open the interview with something like “how can I help you?” or “what brings you to the clinic today?”

If the student states your problem (e.g. ” I understand that you are having problems with your knee”

You should respond “ yes, I wanted someone to take a look at my knee. It is bothering me a lot”

If the student asks you “tell me more about it” or “can you tell me what has been going on”

You should respond “ It’s getting harder and harder for me to do what I want because of the pain”

Context: You retired from your job at American National 5 years ago. Shortly before you retired you noticed that your knee would bother you when you would walk up and down the steps at work. After you retired, you started doing more things with your church and around the house and began to notice that your knee would bother you after you had been active.

Location: The whole right knee hurts. (Note: the left knee hurts a little too, but not nearly as much) When the student asks you where the knee hurts you should put your hand on the front of your knee and rub it almost as a reflex to the question.

Radiation: The pain is localized to the knee joint. It dos not radiate anywhere. There is no numbness or tingling in your lower leg or foot.

Severity: The pain is variable. Some days the pain is a 2-3. Other days it gets as bad as a 7-8. [ On a 1-10 scale (where 10 is the worst pain possible)].

Timing: You have a little bit of stiffness first thing in the morning – it takes you 15 minutes or so to “get going”. The pain is not too bad first thing in the day, but it progressively worsens throughout the day with increased activity.

Aggravating Factor: Activity. Long distance walking (you like to walk your dog) bothers you. Activity that involves a lot of bending of your legs like walking up and down the stairs or if you have to do a lot of bending on days that you clean house is also a problem. Your pain also seems to be worse on damp, cool or rainy days.

Relief by: Your have tried Aleve (you do not remember the strength). It gives you some, but not complete, relief. Sometimes when you are relaxing in the evening or at night, especially on days when you notice swelling in the knee, you use a heating pad. The warmth helps a little. Mostly you just have to get off of your feet and put your leg on a footstool to raise it in order to get relief.

Associated Symptoms: You have occasional swelling towards the end of the day. You feel like you can’t bend your knee completely anymore (limited range of motion). You have not fallen because of weakness or instability in the knee

NOTE: you do NOT have fever, weight loss or any other signs of a generalized illness.

Previous episodes: You have never injured your knee. The pain now is the same as it was when you first noticed it five years ago. It has slowly progressed to the point now where you have pain daily and at times the pain is unbearable

What you think is going on: You have not seen a doctor about the pain but you wonder if you have arthritis.

Prior Hospitalizations: You were hospitalized for the birth of your daughter 35 years ago. You have had no other hospitalizations.

Medical Illnesses: You have diabetes (you were diagnosed about 5 years ago). You have been in very good control – you don’t check you blood sugars regularly – occasionally you dip your urine but it is always negative for sugar. Your last Hemoglobin A1C was 5.

You had one full term pregnancy and uncomplicated vaginal delivery. You went through an uncomplicated menopause at age 56.

Medications: You take glypizide (you think it’s 10mg) one time daily. You use Aleve (2-3 times daily) for your knee

last visit to an MD: You visit your PCP every six months to check on your diabetes and refill your medications. (Quick visits - sometimes you see the nurse practitioner and the doctor just says hello.) At the last visit (4 mo ago) you were told that everything was fine. You have not had a recent well woman check (need to schedule this – you’ve been “so busy”) and you have not seen another doctor or required any specialty medical care.

Your preventive health care checks are not up to date. You do not know your cholesterol level. The doctor wants you to have a screening colonoscopy but you simply have not gotten around to it.

You are not aware of any other major health problems in the family. Specifically no one in your family has had cancer of any kind. If specifically asked, you are not certain if your mother had arthritis

PRESENT LIFE

Occupation: Retired. You worked at American National Insurance Company in the marketing department for 30 years

Sexual History: You are sexually active with your husband only. You have been married for 38 years

Your daughter lives in Beaumont. She attended Lamar University and settled in the area after graduation. She is history teacher at Lamar University.

Your parents lived in Texas City. Your father worked for the refineries. Your mother was a housewife.

Hobbies: You enjoy doing things around the house and walking your dog. You also like to crochet (note: if the student asks, your hands do not bother you when you do needlework).

Religion You are Methodist. You attend church regularly. You are involved in volunteer work through the church at a soup kitchen and at one of the local nursing homes. You enjoy your church work and are concerned that the pain in your knees may interfere with your ability to do everything that you want.

Health Insurance: You are covered by Blue Cross insurance. You recently became eligible for Medicare.

Life Stresses: You perceive very little overall stress in your life. You and your husband are quite happy and enjoying retirement together. Your limitations because of your knee pain are a bit of a stress – you don’t like having limitations on your activities.

Alcohol Use: You have an occasional martini when you go out to dinner (maybe once every two or three months). You never drink at home.

Diet: You eat a healthy diet. You always eat fruit, vegetables and lots of whole grains. You and your husband eat together and mealtime is relaxing time that you spend together.

Caffeine intake: You have coffee in the morning and an occasional cola drink. In the summer months you drink a few glasses of iced tea daily. .

Exercise: You are active. You keep up your home and enjoy being outside with your dog.

Sleep Pattern: You have no problems sleeping. Sometimes your knee pain interferes with your ability to fall asleep. Once you fall asleep you do well through the night.

· You have occasional “leakage” of urine with coughing or heavy lifting. This has been going on for the past 8 years. You have never talked to the doctor about it – it’s a little embarrassing and you assume it is part of “getting older”

Do you think the herbs they have been advertising on TV for arthritis would help my knee pain. (Chondroitin)

The student should carefully (but gently) feel for swelling and tenderness in your knee. They should also flex and extend your knee. Flexing and extending the knee will cause pain. You should limit your motion of the right knee on bending and flexing to ~ 90^o.