Decisional Capacity Case& Vital Signs/Chest Exam

SMALL GROUP SESSION 22

March 6th and March 8th

Decisional Capacity Case& Vital Signs/Chest Exam

Readings:

Review Dr. Davis’s notes from the Decisional Capacity lecture.

Read “A Guide to Assessing Decision-making Capacity”, available at:

Prepare by: Dressing for the chest exam workshop (two piece outfit, sports bra).

Bring:

Physical examination equipment (stethoscopes, diagnostic kits, tuning forks, blood pressure cuff and reflex hammer).

Mentors: Bring physical exam supplies (mats, gowns, handwashing equipment, tongue blades, etc.) Bring a physical diagnosis text.

OSCE sheets for this session.

Brief outline:

Section 1:Touching base (15 minutes)

Section 2: Decisional capacity case (75 minutes)

Section 3: Vital signs and chest exam (90 minutes)

Section 1. Touching base

Section 2. Ethics Case: Decision-making capacity - 75 minutes

A group member should read the case aloud. The group should discuss the questions before moving onto part 2.

Part 1.You are on a team caring for Mr. Jones, a 78 year-old man with recently diagnosed mild Alzheimer’s dementia who is having trouble swallowing. He was admitted to the hospital from his home, where he lives independently after his child, who lives next door, found him lying on the floor, unable to get up. He was brought to the emergency room, where he was diagnosed with a basal ganglia stroke. He initially had weakness on the left side of his body, but that has now resolved. His MMSE score is 23. His main problem seems to be mild dysarthria (difficult speaking secondary to muscle dysfunction) and oropharyngeal dysphagia (difficult swallowing secondary to muscle dysfunction). Although he is able to swallow small amounts of food, he is unable to take in adequate calories. He is being given intravenous (IV) fluids for hydration. A swallowing study demonstrated that he aspirates (allows food into his airway) both thin and thickened liquids in small amounts, increasing his risk of pneumonia. The speech therapist and nutrition consult are recommending placement of a “PEG”(percutaneous endoscopic gastrostomy) tube or nasogastric (NG) tube for feeding. You mentioned this to him during your early morning rounds, and he said “I don’t want any tubes like that.” Your team has scheduled a family meeting with him and his child to discuss this further. Mr. Jones did execute a durable power of attorney naming his child as his medical decision-maker in the event that he was unable to make that decision.

Before going into his room, your team sits down to discuss his case.

What are the medical facts of this case? What do you know? What else do you need to know?

What are the ethical issues involved in this case?

Who are the “players” involved in making the decision? Who will make the decision, and how will this be determined?

What is the setting?

What do you need to find out to determine whether or not Mr. Jones has decision-making capacity?

Section 2. Part 2.

The mentors will play the role of Mr. Jones and his child. The student group members will interview the pair as a team. As with most family meetings, the group should select the roles of the team members. For example, one student could be tasked with explaining the situation to the family, and another tasked with asking questions to evaluate Mr. Jones’ decision-making capacity. Other members should participate. Typically in family meetings, team members will re-introduce themselves if they don’t know the family member particularly well and will ask a question or make a statement. Any group member (Mentor or student) should feel free to call for a time-out to clarify an issue or seek assistance.

After the “family meeting” take a few minutes to debrief. Do you believe Mr. Jones has decision-making capacity for this decision? Why or why not? Do group members believe he is making the right decision? How would it affect your assessment of capacity if he makes a decision that is different from the one you believe is correct? What issues might arise if Mr. Jones came from a non-majority cultural background (African-American, Latino or Hispanic, Asian)?

Section 3: Vital Signs and Chest Exam – 90 minutes

Objectives:

To learn how to take accurate blood pressures

To observe and practice examination of the chest

Overview of blood pressure measurement

Check to be sure patient has not had an arteriovenous fistula or mastectomy – blood pressure measurement is contra-indicated ipsilateral to these conditions.
Select an appropriately sized blood pressure cuff.
Place the cuff snugly about the patient’s arm, with the center of the bladder over the brachial artery, and the cuff 2 to 3 cm above the antecubital fossa.
Support the patient’s arm near heart level.
Palpate the radial pulse.
Pump up the cuff until you cannot feel the radial pulse, and then pump it up an additional 20 mm of Hg.
Deflate the cuff at a rate of 2 to 3 mm Hg per minute and note the pressure when the radial pulse is palpable- the palpable systolic pressure, then deflate the cuff rapidly.
Wait 30 seconds, and then pump up the cuff to 20 mm Hg over the palpable systolic pressure.
While listening with the bell of your stethoscope over the antecubital fossa, release the pressure from the cuff at a rate of 2 to 3 mm Hg per minute.
Note the pressure at which the first two consecutive beats heard (phase I of Korotkoff sounds) - the systolic blood pressure.
Note the last beat heard (phase V of Korotkoff sounds). Deflate the cuff immediately.
Record phase I of Korotkoff sounds as systolic blood pressure, and phase V of Korotkoff sounds as diastolic blood pressure.
The blood pressure should be repeated in the other arm, if this is the first time you have measured the patient’s blood pressure.

ChestExamination Logistics:

Have your mentor demonstrate physical diagnosis of the chest, including:

Inspection: of normal movement of the chest, abdomen and adjacent (accessory) muscles during breathing
Palpation: of surface anatomy of the thorax: include clavicles, scapulae, spine, ribs, sternum, manubriosternal angle (angle of Louis) and xiphoid.
Palpation of the chest: expansion and tactile fremitus.
Percussion- technique; percussion of the diaphragms and diaphragmatic excursion.
Auscultation of the lungs: use of the stethoscope; normal breath sounds in various parts of the lung; posterior and anterior auscultation.
Vocal resonance while auscultating with the stethoscope, ask patient to say “ee”.

After this, break into pairs again and practice examining each other. For this session, we suggest you go into two separate same-gender rooms. Your physician mentor should go from one room to another to answer questions and demonstrate technique.

ATTACHED ARE THE PARTS OF THE OSCE PERTAINING TO CHEST AND VITAL SIGNS. THE SAME SHEETS WILL BE USED TO EVALUATE YOUR EXAMINATION IN THE END-OF-SEMESTER GRADED OSCE.

Part 4: Evaluate Session (10 minutes)

How did this session go? Did you have enough time for each section?

(Remember, this is your first try at chest examination. You will have many more opportunities to practice and learn).

©University of Virginia 2007
O:\Practice of Medicine1\2006-2007\Spring Sessions\Final versions\Session 22\Session 22_decsional capacity case and vital signs chest exam_spring2007_student_nov28.doc

Physical Examination

Objective Structured Clinical Examination (OSCE)

Blood Pressure

A = Attempted Satisfactory B =Attempted Below Satisfactory C=Did Not Attempt

Procedure A B C Comments

Ex slightly flexes patients arm and supports arm (table, hold arm, etc).

2. Ex checks size of cuff, locates brachial artery by palpation, and places cuff snugly about upper arm, centering the bladder over the brachial artery – arm should be free of clothing.

Ex palpates radial pulse, and pumps up blood pressure cuff until radial pulse is no longer palpable, and then rapidly deflates the cuff, and waits 30 seconds before proceeding

Ex places stethoscope (bell preferred, diaphragm acceptable) over brachial artery, pumps up cuff 20 to 30 mm Hg above palpable systolic pressure, and then releases cuff slowly, at rate of 2 – 3 mm Hg per second, listening forKorotkoff sounds.
Ex records blood pressure.
4.PULSE: Ex palpates the radial artery for at least 15 seconds.
5. RESPIRATION: Ex stands in front of or behind pt and observes breathing at rest for at least 30 seconds (normal rate is 10-16 breaths per minute). Ex states respiratory rate.

Physical Examination

Objective Structured Clinical Examination (OSCE)

Chest and Lung Examination Checklist

A =Attempted SatisfactoryB =Attempted Below Satisfactory C =Did Not Attempt

ProcedureA B C Comments

1. INSPECTION OF CHEST: Ex visually inspects Pt’s chest while sitting for shape and symmetry, symmetry of respiratory excursion, pulsations, heaving and respiratory effort. (Ex states what they are inspecting for)
2. THORACIC EXPANSION: While standing behind Pt, Ex places thumbs parallel and several inches lateral to pt’s mid to lower spine. Ex then asks Pt to inhale deeply while Ex feels the range and symmetry of Pt’s respirations.
3. TACTILE FREMITUS: While standing behind Pt, Ex places his/her palmar surface of both hands on Pt’s upper, middle, and lower back. Ex asks Pt to recite a few words or numbers (ex. “99”) while Ex palpates with a firm, light touch both sides simultaneously.
4. PERCUSSION: Ex percusses over posterior and anterior chest. Ex moves from one side across to the other and down.
4a. PERCUSSION TECHNIQUE: Ex places middle finger, which is hyperextended, against pt’s skin, lifting the rest of stationary hand up. Using the middle finger of the dominant hand, ex bounces it off the stationary one.
5. DIAPHRAGMATIC EXCURSION: Ex asks Pt to “take a deep breath and hold it” while Ex percusses down the scapular line. Ex then asks Pt to “exhale and hold it” as much as possible while he/she percusses the back. Both inhale and exhale percussion procedures should be done on both sides of the Pt’s back.
6. POSTERIOR BREATH SOUNDS: Ex asks Pt to breathe deeply through mouth while Ex listens to AT LEAST ONE FULL BREATH AT EACH POSITION on the back. Ex moves from one side of the back across to the other and down.
7. ANTERIOR BREATH SOUNDS: Ex uses stethoscope to listen to both sides of the front of Pt’s chest. Ex progresses from side to side moving downward using the same sequence while listening to one full respiration on each location.
8. AUSCULTATION TECHNIQUE: Ex listens to the Pt’s chest using the diaphragm of the stethoscope, which should be pressed firmly onto chest.
9. VOCAL RESONANCE: While auscultating with the stethoscope over the back, the examiner asks the patient to say “E.” Ex moves the stethoscope from one side to the other, moving downward, while listening to patient say “E” at each location.