SP Training Notes

Medical College of Wisconsin

GET- Cardiology OSCE Session #1

Mrs. Mary Frederickson

Patient Name: / Mrs. Mary Frederickson
Gender/Age: / 80 year old woman
Brief Summary: / Mrs. Fredericksonis a woman who has an undiagnosed dementia that is of an early to medium degree. She lives alone at home. She has been having more difficulty managing her household activities and needs since her husband died 6 months ago. Over the last day, she began feeling weak, tired and nauseated. She told that to her daughter, who brought her to the Emergency Room. The patient was then diagnosed with a non ST elevation MI (a myocardial infarction/mild heart “attack”). She was admitted to the internal medicine ward for care overnight. The internist consulted the cardiology team the next morning to see if Mrs. Frederickson needs to have a cardiac procedure done. The cardiology fellow is coming to obtain consent from the patient for a cardiac catheterization procedure.
In the hospital, Mrs. Frederickson has become quite confused due to her illness (delirium) in addition to her underlying dementia. She has difficulty understanding the physician in order to give consent for the procedure. She is having trouble with her memory, difficulty paying attention, and doesn’t realize she is in the hospital. Her daughter is with her. The physician needs to recognize that the patient is having difficulty with her thinking and is unable to give consent for the procedure. That consent needs to be obtained from the Power of Attorney for Health Care (POAHC), the patient’s daughter.
Key “Findings” for the SP Patient to Portray: / Overall: Patient is in bed or lying down on the exam table; her daughter sits next to her. The patient has early to moderate dementia, and is now more confused and sleepy (more lethargic) because she is ill. Please answer the physician’s questions, but at times, answer in a vague and uncertain manner, slowly at times, and at times looking to your daughter for help. You do not think that you have any difficulty with your memory or your thinking.
Verbal: Answers general questions easily (e.g., how are you feeling – “just a bit tired; I’m here because my daughter was worried”) – but no details about medical hx, last hospitalization (tries but struggles, looks to daughter for answers).
  • Answers are “short”/ “brief” due to being sleepy. She has difficulty paying attention and appears distracted.
  • Patient has difficulty answering some questions and appears “puzzled”. She looks to her daughter to answer
  • Only answer questions when they are asked. Do not volunteer information or initiate conversation
  • Answers are short, vague, and sometimes incorrect
  • She doesn’t know the month, date and year (if asked)
  • Speaks slowly
Non-Verbal: The patient easily drifts off to a light sleep, closing her eyes and leaning her head back, but she arouses to voice and touch. She answers the question or looks to her daughter to answer the question, but then sometimes drifts back off to a light sleep again for a few seconds.
Answers to specific questions (that may be asked):
  • What is the date? Where are you?
Not certain of where she is (place) or the date/year.
  • Do you have any trouble with your memory?
No, my memory seems to be fine for someone who is 80!
  • Memory is impaired—misses items on the 3 item recall test, has difficulty with the clock draw test, misses some items on the MOCA.
  • Confusion: does not completely understand what the physician is trying to tell her about her heart and the procedure that is being discussed.
She may respond to questions with repeated phrases (e.g., “I think that I need to go home, now”, “I need to check with my husband”). She has difficulty remembering the details of what the physician told her about her heart and the procedure.
  • She is not able to make a choice about whether to have the procedure done or not. She keeps saying, “I’ll be fine soon. This is all fine.”
  • Does not speak too much, relies on (looks to) daughter to answer most questions

Key “Findings” for the SP Daughter to Portray: / Overall: The daughter is sitting next to the patient. She is there to support her mom while she is in the hospital. The daughter is aware that her mom is having more difficulty with her memory, having more trouble with bills, pills, appointments. Since the patient’s husband recently died the daughter has been helping her mom more with those details. Her mother has never been diagnosed with dementia, or “Alzheimer’s” and the daughter attributes these changes in her mother’s memory and abilities to “normal changes in memory for an older person.”
  • Daughter answers questions for her mother when her
mother looks at her for help or when the MD asks the daughter the questions directly.
  • Daughter answers the questions about her mother’s memory
and function and home situation difficulties simply, and directly, but does not volunteer the information unless she is asked
  • Daughter will tell the MD that her mother’s thinking is now different than it is at home. This is a change and her mother is much worse. she sometimes “doesn’t even know me.”
Background history
Mom’s cognition:
  • Mom’s thinking has been “pretty good for someone her age”, but she has some repetition of questions and doesn’t always remember what she was told about various things/events.
  • Sometimes Mom has difficulty with understanding why things are a certain way—or how things work (e.g. trouble managing her new phone, when the light bulb burned out she called the electrician to come to the house to replace the bulb, she recently gave substantial donations to both political parties because she “thought then they would work together better”.
  • “Mom’s thinking is much worse over the last day or two. She now seems more confused than usual. She is just not herself. This is not like her to be so sleepy, and to sometimes not even recognize me.”
Mom’s function/social situation:
  • Things having been more difficult for the patient now that her husband has died. He was very helpful in keeping everything going. Now the daughter is needing to be more involved and she is taking additional time on the weekends to help her mom with bill paying and setting up her medications. The daughter has started to bring some meals over to her mother’s house for dinner because she thought she might be losing a little weight.
  • Some trouble remembering things(occasional missed appointments, occasional missed meds, bill paying now that Dad has died). Mom is still able to do her own dressing, bathing, uses the phone. Areas of problems are “bills, pills, and appointments”.
  • She had one small car accident last month where she “rear-ended” the car in front of her at a stop light. No one got hurt and the insurance paid for the car repairs.

SP Patient Opening Statement: / “I just don’t feel too well today. I felt worse yesterday but today I still don’t feel well.”
Elaboration of Complaint:
(if asked by MD) /
  • I am tired, I am in the hospital.
  • I felt sick yesterday, and weak. I almost fell down when I got up from my chair, but my daughter “caught” me.
  • My daughter brought me to the hospital
  • “The doctors tell me that there is a problem with my heart”

Memory/Concentration /
  1. Memory or concentration
  2. How is your memory or thinking?
“I think my memory is pretty good and I’m still doing well”
  1. Can you recall a recent news story?
“Hum – I can't recall any recent stories right now.”
  1. Who is the president of the USA?
“Maybe George Bush?”
  1. Do you know where you are now?
“ I think maybe a nursing home”
  1. If asked date, time, location:answer 2 of 3 Incorrectly
  2. If asked to remember three objects (fellow states the objects and asks you to remember them): You recall only one of them correctly
  3. If asked to draw a clock with hands pointed to a certain time: do this correctly except have a little trouble with placing the hands on the clock face to show the time asked.

Family Medical History / Daughter can answer these if asked
  • Father passed away from a heart attack at 76 years of age.
  • Mother died at the age of 88 from dementia

Social History /
  • College graduate with a degree in teaching, retired elementary teacher
  • Live in the family home by yourself as your husband died 6 months ago from cancer
  • Social Support: “My daughter lives near me”