Vignette Instructions:

This vignette is designed for a five day rotation but can be adapted to fit varying rotation lengths.

Students are assigned the “student version” vignette on day one of the rotation. The student version does not have the answer prompts.Students are to read and complete each day, starting the first day on service. The following day, ask your trainee for their written responses, discuss that day’s vignette, answer any questions, provide feedback and sign off on that day. Discussion of the questions and answers are encouraged to enrich and standardize the learning experience for students at diverse training sites. By the end of the rotation all student responses to questions should be completed with your signature.

It is important that each day’s questions are completed before going on to the next day of the vignette. Please have trainee complete one day’s questions nightly until all of the questions have been completed. This means that trainees will be working on a day from this case Monday-Thursday and discussing a day of the case with you from Tuesday-Friday.

Student Instructions:

This clinical vignette is designed to evaluate your skills in specific areas of Geriatric and Palliative Medicine. It is separated into four days. Complete one day of vignette starting Monday and finishing Thursday.

  1. Read the case.
  2. Complete the assigned questions for the day.
  3. Discuss your responses with your preceptor the next day. Your preceptor will review your answers, provide feedback and sign off on that day.
  4. By the end of the rotation, allquestions related to the case must be completed and signed by your preceptor.

DAY 1

Complete on day 1 of your rotation – review with your preceptor on day 2

There is a signoff area here for the Preceptor’s Signature on the trainee’s document ____

Mr. Xavier Sperry, a 73-year-old male, is hospitalized due to weakness and a non-traumatic fall in his home. Mr. Sperry has a past medical history of hypertension and generalized anxiety disorder. Social history is significant for smoking history (1 pack/day), but no illicit drugs or alcohol. Pertinent review of systems includes generalized weakness and pain over the past two weeks, reduced appetite and trouble with sleeping over the past four days. Medications include Lisinopril and Ativan 1 mg q 8 hours (for 6 years). You round in the morning with the attending physician, who stops with his hand on the door and says, “We are going to investigate the reason for Mr. Sperry’s fall.”

A) Identify 4 common risk factors for falls in the elderly:

B) Identify approaches to prevent falls in the elderly

Source:Todd C, Skelton D. (2004). What are the main risk factors for falls among older people and what are the mosteffective interventions to prevent these falls? Copenhagen, WHO Regional Office for Europe Health Evidence Network report.Retrieved from

C) Identify common medications that contribute to falls in the elderly

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Source: Adapted from Tinetti ME, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med. 1994;331:821-817. Copyright  1994 Massachusetts Medical Society. All rights reserved. Adapted with permission.

DAY 2

Complete on day 2 of your rotation – review with your preceptor on day 3

There is a signoff area here for the Preceptor’s Signature on the trainee’s document ____

The attending discusses the Beers List of Inappropriate Medications in the Elderly, and quickly the team identified Ativan (a benzodiazepine) as an inappropriate medication for Mr. Sperry that likely precipitated his fall. The Ativan was quickly discontinued,and the team proceeded to work up Mr. Sperry’s unwitnessed fall (underlying systemic or metabolic process e.g., infection, electrolyte imbalance as indicated by history, examination, orthostatic blood pressures, imaging and laboratory studies, etc.). The next day, Mr. Sperry was severely agitated, hallucinating and combative with the nursing staff. To prevent another fall, the nurses called the float and received an order for Benadryl to help the patient sleep. This report was transcribed in the patient's chart prior to your review of pending diagnostics from the day before.

A) What syndrome best fits Mr. Sperry’s change in status?

B) What is the differential diagnosis of the cause of this patient’s change in mental status? (List five common causes for this diagnosis, with examples of each)

C) Name at least five drug classes that commonly contribute to this problem

D) Describe at least 2 non-drug treatments for this problem, as well as one pharmacologic treatment of this problem. For the drug treatment, write an appropriate order for the drug’s administration.

Non-pharmacologic management

Pharmacologic management

DAY 3

Complete on day 3 of your rotation – review with your preceptor on day 4

There is a signoff area here for the Preceptor’s Signature on the trainee’s document ____

The attending restarted the pre-hospital dose of Ativan for one day, and reduced the dose to 1 mg BID, and removed unnecessary restraining devices in the morning (IV fluid and indwelling urinary catheter). The patient’s delirium improved significantly from the day before, and he is discharged from the hospital.

The next day, Mr. Sperry complains of significant pain, which is 8/10 at rest and 10/10 with movement. The pain is described as a constant, dull aching pain and localized to the back; the pain worsens with movement or coughing. He visits the office in a rented wheelchair due to the unbearable pain when he walks. When asked, he reports decreased sleep for the last week due to the pain, and inability to complete his usual self-care and household tasks. His current available pain medication is Hydrocodone/APAP 5/500mg q4 hrs PRN, and he is taking an average of 4 pills/day.

A) You have already been given most of Mr. Sperry’s pain assessment. What else would you like to know before developing an opioid analgesic regimen?

B) Please write out an initial opioid drug regimen for this patient; include generic name, strength/dosage, whether scheduled or prn and dosing interval, and an appropriate bowel regimen:

  1. Long-acting opioid:
  1. Short-acting opioid:
  1. Bowel regimen:

C) The patient follows up with his physician on Monday and reports that the back pain has improved, but is still 3/10 at rest, increasing with movement. He is using his short-acting medication 2-3 times a day. He is not having any adverse side effects from the medication, has had normal bowel function, and is careful not to drive when taking his medication, as ordered. His physician wishes to adjust his medication regimen to allow for better pain control. Please suggest a dose or drug adjustment to your original prescription:

DAY 4

Complete on day 4 of your rotation – review with your preceptor on day 5

There is a signoff area here for the Preceptor’s Signature on the trainee’s document ____

Next, the attending physician discusses the findings of his hospital work-up. In the initial chest x-ray from the ER, he was found to have an infiltrate on chest x-ray. A CT scan of his chest showed a 4x6 cm mass that appears consistent with lung cancer. The patient opted for a biopsy of the pulmonary mass, and the pathology report revealed poorly differentiated adenocarcinoma.

Mr. Sperry’s progressively intractable back pain was worked up; plain spine x-rays show vertebral compression fractures at T8 and T12. A follow-up spine MRI shows multiple thoracic metastases, but no spinal cord compression. Various family members are with the patient around the clock waiting to see what the attending physician has to say. You round in the morning with the attending physician, who stops with his hand on the door and says, “We are going to have to tell Mr. Sperry the bad news about his CT scans today.”

A) Based on Baile (2000), SPIKE protocol, outline a 6-step approach to use when discussing the bad news with Mr. Sperry—list the recommended steps, in order. An asterisk is placed next to the steps where you can try to formulate a sample sentence that you could say to this family.

STEP 1:

*STEP 2:

STEP 3:

*STEP 4:

*STEP 5:

STEP 6:

B) Explain the recommended physician response if the patient/family becomes very emotional (crying, distraught) after receiving bad news:

C) What three items must be documented in the patient’s chart after a “bad news” discussion?

Source: Baile, W. F., R. Buckman, et al. (2000). "SPIKES-A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer." The Oncologist5(4): 302-311.

Vignette Resources

Note: This reference source appears on page one (after the cover page and the Introduction) in the student’s document

Baile, W. F., R. Buckman, et al. (2000). "SPIKES-A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer." The Oncologist5(4): 302-311.

Gordon D. PRN Range Analgesic Orders, 2nd Edition.Fast Facts and Concepts.July 2006; 70.

Available at:

Physicians Desk Reference. Available at:

Weissman DE. Opioid Dose Escalation, 2nd Edition. Fast Facts and Concepts.July 2005; 20.

Available at:

Weissman DE. Oral Opioid Dosing Intervals, 2nd Edition.Fast Facts and Concepts.July 2005; 18. Available at:

Weissman DE. Oral Opioid Orders: Good and Bad Examples, 2nd Edition. Fast Facts and Concepts.July 2006; 74. Available at:

Todd C, Skelton D. (2004). What are the main risk factors for falls among older people and what are the mosteffective interventions to prevent these falls? Copenhagen, WHO Regional Office for Europe Health Evidence Network report.Retrieved from

Vignette revised by Shannon Pearce, DNP, Grace Varas, DO, and Jennifer Larson, MSE with permission by Amy L Holthouser, MD.

Designed by Beth Watson in the Multimedia Scriptorium at The University of Texas Health Science Center at Houston.

Photographs are allowed by the MorgueFile free photo agreement and the Royalty Free usage agreement at Stock.xchng. They appear on the first page in this order:

Wallyir at morguefile.com/archive/display/221205

Mokra at

Clarita at morguefile.com/archive/display/33743

The Training Excellence in Aging Studies (TEXAS) program promotes geriatric training from medical school through the practicing physician level. This project is funded by the Donald W. Reynolds Foundation to the division of Geriatrics and Palliative Medicine within the department of Internal Medicine at the University of Texas Health Science Center at Houston (UTHealth).

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