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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 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: 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: 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