MPS-1 Geriatric Module
Script 2
PLAYERS:
1. Mr. Forman- recently evaluated in the emergency room for chest pain. Now referred to a primary care physician for ongoing care and continued evaluation of chest ache.
2. Mrs. Olson—Mr. Forman’s concerned daughter. She is a profession woman, busy and stressed. She wants the best care for her father but has little time given her other commitments at work and home.
3. Ms. Sheridan- An experienced nurse, with training in geriatrics. Insightful, professional and kind
4. Dr Kramer- An experienced internist with a holistic approach to caring for patients
Primary Care Office:
Nurse: Good morning, Mr. Forman. My name is Mary Sheridan. I’m the nurse working with Dr. Kramer. (shakes patients hand).How are you feeling?
Patient: I’m feeling fine, thanks. Just here to get checked out.
Daughter: He’s far from fine! ..I’m his daughter Julie Olson. He’s here because he’s been having chest pain. He was in the ER all night last week but they couldn’t figure out what it was. Hopefully this doctor will be more helpful.
Nurse: I see. (to patient) How have you been doing over the past week? Have you had any more episodes of pain?
Patient: It seems like it’s there all the time-sometimes worse ,sometimes better. It’s hard to describe. I notice when I’m at the theater rehearsing it seems to come on.
Daughter: There’s a surprise, Dad!
Patient: Unfortunately I’m missing rehearsal right now..
Nurse: Oh, you’re involved in the theater?
Patient: (looking more animated) Yes, I am. My wife and I were very involved in our community theater group. Boy, we had some swell times…
Nurse I can imagine. What show are you working on now?
Patient: South Pacific
Nurse Oh, that sounds great! That’s quite a production though, huh?.. Is your wife in it too?
Daughter: No, she died last year – about 6 months ago.
Nurse I’m sorry to hear that..
Patient: Oh, she would have loved this production. She was a real Rogers and Hammerstein fan. And what a voice she had… She was the singer and I was the dancer-we were some team..
Nurse It must be hard for you without her now. How are you managing at home?
Patient I’m getting by…
Daughter: I don’t know about that- I think we’re going to have to get him some help soon
Nurse: Well Mr. Forman if you ever feel you need some assistance at home our social worker can certainly help you with that. Is there anything other than the chest pain that you would like speak with Dr. Kramer about today?
Patient: Well maybe my sleep. I seem to be having some trouble staying asleep-you know-waking up early. It’s making it hard for me to concentrate the next day. Learning my lines is tough if I’m too tired
Nurse I see. That really is a problem. I’ll make sure Dr Kramer knows. Anything else?
Daughter: Look, I think our main concern here is finding out what I causing this chest pain. That’s really our priority today.
Patient: The only other thing is I think my prostate might be acting up-- it’s been a little hard to urinate lately.
Daughter: Jeez Dad--you’re falling apart
Nurse That’s a fairly common problem Mr. Forman. I’m sure Dr Kramer will be able to help you out with that. I’ll let him know your concerns and he should be in shortly. Are you comfortable there?
Patient: I’m fine thanks.
Daughter: Can you tell me how long that’s going to be?
Nurse: It shouldn’t be too long.
Nurse relays information to Dr Kramer in the hallway
ENTER DR KRAMER
Doctor: Good morning, Mr. Forman. I’m Dr Kramer.
Patient: Good morning Doc.
Daughter –(extending her hand) Hi-I’m Julie--Julie Olson. I’m the daughter.. I’ve been so anxious to meet with you doctor. We’ve been worried sick ever since that emergency room visit last week. I’m absolutely certain there is something terribly wrong with his heart but no one seems to be able to tell me anything.
Doctor: (to daughter) It sounds like you’ve had a hard week. I’m sure by the end of the visit we’ll have a better idea of what’s going on.
(to patient) Mr. Forman, how would you like me to address you?
Patient: Please, call me Joe. Everyone does
Doctor: OK Joe. Now I understand from our nurse Mary Sheridan that you were seen in the ER last week for chest pain? Can you tell me a little about that?
Daughter: I can tell you exactly what’s going on. He’s 80 years old and he can’t quite seem to accept the fact that he can’t do the things he used to. Do you know what he was up on stage dancing when he got chest pain? Can you believe that?
Doctor: (To daughter) Well, we certainly have a lot of vibrant older adults in our practice Julie. Joe, why don’t you tell me more about the chest pain you experienced?
Patient: Well, Doc, it’s really not a pain. That’s what I’ve been trying to tell everyone. It’s kind of like an ache or a hollow feeling in my chest. It’s almost always there but seems a little worse when I’m at the theater or late at night. It’s not so bad. I’ve been living with it.
Daughter: Excuse me doctor but you should know that his father had a heart attack. I really want to make sure you do some tests on his heart. I’m sure there’s something wrong.
Doctor: I understand your concern, Julie, but let me just hear a little more from Joe.
(To patient) Joe, how long have you had the problem?
Patient: Less than a year. I don’t know exactly, maybe more like 4 months or so.
Daughter: And you never told me. I don’t know Dad. What other surprises do you have in store for me?
Doctor When you get the pain do you have any other symptoms like shortness of breath or dizziness?
Patient: No
Doctor: Do you have extra heart beats or palpitations
Patient: Not that I’ve noticed
Doctor: Have you noticed any pattern to the pain?
Patient: That’s the weird thing, Doc. I can just be sitting around thinking and all of a sudden it’ll come on stronger.
Doctor: I see from the Emergency Room notes that they really didn’t feel it was your heart
Daughter: I wouldn’t trust that too much.
Doctor: (to daughter) I’ll tell you Julie, they really did have an amazingly thorough evaluation and nothing yet seems to indicate a heart problem.
(to patient) Joes, it looks like the cardiologist saw didn’t feel there was a problem. You even had a Thallium stress test to look a t the coronary arteries and those looked fine. Have you ever had acid stomach or heartburn?
Patient: No
Doctor: Did the pill that the emergency room doctor gave you help at all?
Patient: Can’t say as they did, Doc.
Daughter: Now that’s exactly what I’ve been talking about! Why on earth was he given something for his stomach when this is clearly a heart problem?
Doctor: Julie, very often acidity can often cause chest pain. Joe, do you have any ideas about what might be causing this ache?
Patient: (hesitates) Uh, I don’t know… probably just old age
Doctor: Well you know, chest pain is not a part of normal aging. When someone has chest pain it really needs to be evaluated. So let me start by examining you Joe. Why don’t you go into the exam room a get a gown on? Julie, perhaps you can wait in the waiting room during the exam and we’ll talk at the end.
Daughter: Oh, sure....
(Daughter leaves)
Doctor: Joe, I would like to start asking you some questions about you life since this is the first time I’m meeting you. Is that OK?
Patient: Fire away, Doc.
Doctor does the Enhanced Social History/ Life Review (not really scripted, BUT following are highlights of points patient makes during the history)
Patient Profile:
Upbringing: Parents from Europe. Working class: father tailor; mother housewife. They embraced the classics-instilled this in their children-love of reading. Joe went off to the army-returned-studied literature-got involved with theater, etc
Occupation/retirement Literature teacher -- retired at 70
Age-80
Religion/spirituality: Theater can teach us a lot about spirituality-South Pacific. You’ve got to be taught to hate and kill etc. etc.(sings)
Residence: Single family-2 stories-Lynn inherited it from her parents We had our girl out in California then came back out eat and moved into the house-it’s held up well.
Economic/insurance/prescription coverage: Lynn’s illness took most of what we had..that’s a little tough. No prescription drug plan-has to pay for that himself-“It adds up”
Lifestyle
Smoking: “I lived with a singer doctor!” “No smoking in that house-not even incense!”
Alcohol: Increased Alcohol since wife died to sleep. “Lynn and I would have what we called a cocktail in those days-I still do in her memory” “Occasionally at night I’ll have one too-you know to help get to sleep. And of course you need a beer or two to wash down lunch right?
Nutrition: Well you know doc-life in the theater-you grab a bite when you can. But yeah-I have lost weight-I can tighten the belt another notch lately..
Environmental impediments/Home safety:
Well yes-I have had a few falls-maybe 2 in the last 8 months. One when I left my glasses downstairs and missed a step going down. Then once in the bathroom-the curtain was out and I slipped on some water. And of course this winter was bad with the ice -- I guess that makes 3 huh?
Stress/Mental health/depression: Depressive symptoms: Tearful/sleeps poorly-early morning awakening/appetite-no taste for food usually. “Every now and then when I see something of hers….”
Relationships
Family Patient expresses sadness re: wife’s death “heartache”
Household Composition Expresses some tearfulness when talking about wife
Friends/Peers/support Doesn’t want to worry daughter/ Stress reaction postulated as cause of chest pain
Have a couple of old buddies from the army he can still talk to and sees fairly regularly
Loves daughter but doesn’t feel close to her
Sexual activity Had great sex life with wife, but now has no interest since her death
Advance Directives & few other questions…..
Doctor: Joe, I have a pretty good idea about you medical history from you previous records that you brought and from the emergency room and what Julie brought me from you last doctor.
Doctor: Now I’d like to do a complete exam.
Patient: Sounds good. I’m really concerned about my prostate. Can you check that out for me?
Doctor: Certainly
Doctor does complete exam/darken lights
Doctor: Your exam was pretty good Joe. I didn’t find any abnormalities with your heart or lungs..You do have a slightly large prostate, which is common for men as they age but nothing to suggest cancer.. It explains your difficulty urinating, though. I can give you some medication to try for that.
Patient: Great Doc. I was really worried it was cancer.
Doctor: I think the next step is to talk about your chest discomfort and what appears to me to be a depression. It seems that since your wife died, Joe you’ve had all the symptoms of depression. You’re tearful, you’re having problems with you sleep, your appetite isn’t what it used to be – your alcohol intake has increased.. All of these are symptoms of depression. And actually, I think the ache in your chest may be a manifestation of depression as well. The good news is that I think we can get you feeling much better by treating the depression.
Patient: That sounds OK to me Doc.
Doctor: I would like to call Julie in to discuss our plan. Is that OK?
Patient: Oh good. I know she’s worried.
Doctor leaves and gets daughter. They enter
Daughter: So Doctor Kramer, can you tell me what’s wrong with my dad?
Doctor: Well Julie he’s actually doing pretty well physically. His heart and lungs seem fine. His prostate is a bit enlarged but we can easily treat that with some medication. I did feel he was a little deconditioned and a physical therapist might be able to help with that . I am a little concerned about the alcohol use but I think that’s because he’s experiencing a depression. And it’s very likely that the ache he’s feeling in his chest is related to the depression and not to any heart problem.
Patient: It looks like I might be under too much stress. Doc says it can cause that aching in my chest. It has been a hard year…
Daughter: Stress? But dad, it’s been 6 months since Mom died.
Doctor: Well that’s not very long, Julie. The loss of a spouse – and a parent -- can be very stressful.
Daughter: But what I really need to know is, is he imagining this chest pain? This isn’t mental illness is it?
Doctor: Julie what your father is experiencing is a major depression. A lot of times physical complaints can be a manifestation of depression, but the good news is that we can easily treat it.
Daughter: (Begins crying)
Doctor: Are you OK Julie?
Daughter: (Tearful) I just feel like I haven’t been minding the store here.
Patient: That’s not true honey.
Daughter: I’m so concerned about him because-well-I really miss my Mom and I don’t think I can handle losing my Dad as well…
Doctor: I think he’s going to be fine, Julie. Joe, we need to do the following: First we have to give you an antidepressant, which I’m confident will help. Then we can set you up with a social worker for ongoing therapy. In fact it might be good for you, Julie, to get some help as well. You both have had a hard time.
Why don’t I write out your prescription and our nurse will go over the specifics with you. Give me a call in a week or so and let me know how you’re doing with the medication and then we’ll touch base again in a month or so. Sound OK?
Patient: I think you covered it all Doc. Thanks a lot. I feel better already.
Doctor: I’m glad to hear that.
Daughter: Doctor, I’d really like to be with him for his next appointment. Is that OK?
Doctor: How do you feel about that Joe?
Patient: I wouldn’t have it any other way.