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Medical College of Wisconsin
Geriatric Cardiology
Case Development Blueprint
Presenting Complaint:
“I'm short of breath and my legs are swollen… seems like things are not
going as well as I thought."
Gender and Age:
83 year old man
Patient Name:
John Smith
Brief Summary:
Mr. Smith is an elderly patient who has recently moved back to the area.
His new primary care physician has referred him to the cardiologist for
further help in managing the patient’s complex cardiac situation. The
patient is now being seen by the cardiologist to review his care and to
determine the next steps in management of his cardiac care.
Past medical history:
Hypertension
Dyslipidemia
CAD s/p CABG (x2000,2008)
Chronic atrial fibrillation, on warfarin
Heart failure LVEF 15-20% (NY class IV), due to ischemic cardiomyopathy
Recent echo- severe biventricular failure, RV severely enlarged, PAP 65
mmHg
AICD placement (battery life expires in 1 month)
DM II
Chronic kidney disease stage 3
Falls (x2) over 6 months
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The patient has had four hospitalizations due to heart failure
exacerbations within the past 6 months. He reports good adherence
to his medication regimen and he receives home health care services
for a few weeks after each hospitalization.
Despite this care, he has shown gradual functional decline within the
past 6 months. He is currently able to ambulate with a cane, but only
able to walk short distances due to dyspnea and fatigue.
Case Objectives:
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Key “Findings” for SP
patient to Portray:
Patient demeanor:
 Sitting in chair or on examination table wearing oxygen cannula
 Alert but tired, appears worn out
 Mildly short of breath (about 1.5-2 times normal breaths per minutes)
 Able to answer questions but answers are short and brief (due to
Identify end stage cardiac disease in an elderly patient
Determine the patient’s cognitive and functional capabilities
Elicit the patient’s goals of care
Make care recommendations that are consistent with the patient’s
life and care goals.
o Recommendations:
 to not replace AICD battery
 palliative care/hospice care
dyspnea)
 Occasionally taking deep inspirations to “catch your breath”
Patient /physician interaction content:
 Patient has no memory problems
 Patient has difficulty with ADLs: ambulation, bathing, dressing,
(due to dyspnea and fatigue)
 Difficulty with IADLs of driving, grocery shopping, laundry (dyspnea),
but takes care of bills, pills, phone with no difficulty
Patient goals of care:
The patient feels tired and fatigued. When the physician initiates a
discussion of goals of care, he is able to come to the conclusion, albeit
reluctantly, that his heart is in very bad condition. He is accepting of
conservative measures that will continue to prolong his life (medications)
but does not want resuscitative (CPR. ventilator) measures. He is
accepting that not replacing the AICD battery is an appropriate course of
action. He is willing to hear about how a palliative care approach or
perhaps care through hospice may benefit him, but he is not ready to
“sign on” right away.
Key Teaching Points of
Case:
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Identify end stage heart failure in an elderly patient
Determine the underlying physical, cognitive, social context of that
patient with cardiac disease
Elicit the patient’s care goals and make recommendations for
conservative care
Exam Room Needs:
Chair for patient, or may use the exam table
Chair for physician (fellow)
Chair for observer physician (fellow)
Oxygen tubing for patient
“Door Sign” direction sheet
Activities & Time Req:
20 minute session=
(17 minute SP session, 3 minute SP debrief)
Course, Student Level:
Cardiology fellow: PGY4-PGY6
Date (orig. / last revision)
September 2012
Authors:
G. Manzi, K. Denson