Download Medical College of Wisconsin

Mr. Merrill
SP TRAINING NOTES
Patient Name
Mr. J. Merrill
Gender/Race/Age (range)
Male, Age 80
Presenting Situation
Opening Statement (from
daughter)
Elaboration of Complaint
Patient’s Demeanor
The Emergency room resident calls the nephrology fellow to evaluate Mr. J.
Merrill as the lab work revealed elevated creatinine compared to baseline.
Baseline creatinine is 1.7 mg/dL and now it is elevated to 5.0 mg/dL.
“My father is just not himself lately.... I’m really worried. His legs appear
swollen for the past few days and today he is also complaining about shortness
of breath when he walks around.”
 Two weeks previously the patient was admitted to the hospital for
cellulitis. He was discharged home with IV antibiotics.
 He is getting IV antibiotics at home with the help of a home nurse.
o If asked which antibiotic Mr. Merrill is on – say “IV Vanco
something”.
 He did fine initially with some improvement of his cellulitis but has been
confused for the past 3 – 5 days.
 Patient noticed leg swelling for past few days.
 Last night he could not sleep well and he also was complaining of some
shortness of breath today.
 Daughter happened to stop by her father’s home earlier today while the
home care nurse was at his house.
o Home care nurse advised the daughter that her father’s mental
function had declined over the last 3 – 5 days and now he is
experiencing leg swelling and some shortness of breath.
o No previous Leg swelling
 Nurse contacted the primary care physician who advised the nurse to have
the daughter bring the patient to emergency room.
 The daughter is with the patient in the emergency room and is his power
of attorney for health care (confirmed by resident).
 Patient is in a wheelchair
 He is alert, but prefers to sleep
 Mildly Short of Breath – about 1.5 - 2x the normal breaths (about how
you’d feel if you climbed 2 flights of stairs).
 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).
o ANSWERS ARE “SHORT”/ “BRIEF” DUE TO SHORTNESS OF BREATH & FATIGUE
o EVERY 3RD QUESTION PATIENT, “PUZZLED” LOOKS TO DAUGHTER TO ANSWER
o IF PATIENT TOO “LIVELY – ORIENTED” DAUGHTER “CORRECT” THE PATIENT
(SERVES AS REMINDER TO PATIENT TO STAY IN “CONFUSED”, SHORT OF
BREATH, & FATIGUED ROLE)
 Non-Verbal: Hands and arms occasionally “twitch” (as if you are about to
catch a ball and your hand opens) – or if the patient moves his hand he
has hand tremors (but not continuously).
o Occurs every 2-3 minutes
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Clinical Content*
Present illness/symptoms:
 I think my daughter brought to me to the hospital*
IF ASKED (Do not volunteer information):
DAUGHTER ANSWERS MOST OF
1. How long this has been going on
QUESTIONS.. (PT ANSWERS ONLY
o I don’t know*
* QUESTIONS)
o Daughter - Leg swelling for the past 3 – 5 days but shortness of
breath developed just today.
IF ASKED:
Shortness of Breath
1. Tell me more about the shortness of breath
a. I really never have been short of breath before today*
b. Daughter - Always pretty active, walks regularly.
2. Have you been awakened at night – from shortness of breath?
a. Yes – last night*
b. (PAUSES and then says) I asked that nurse for a few more pillows
to sleep on at night*.
3. Chest pain?
a. No*
4. Fever?
a. No*
5. Palpitations? (feeling of heart beating normal/fast)
a. No*
6. Do you have any fever, cough or sputum production?
RESPIRATORY SYSTEM
No*
7. Legs swelling
LEG SWELLING
a. Yes… seems to have started a couple of days ago.*
b. Daughter- The nurse noticed and was concerned. It seems that it
has been slowing increasing for the last couple of days
Present Illness/Symptoms
CELLULITIS
SKIN
LIVER
BLADDER/BOWEL
GU/URINE
8. Is the leg infection getting better?
a. I think so*
9. Any rash on the skin?
a. The skin infection (cellulitis) seems to be getting better*.
b. Daughter - The nurse said there are no new rashes on his skin
10. Any itching of skin?
a. No*
11. No one ever said anything about my liver*.
12. Daughter: No problems that we know of.
13. Have you noticed any changes in your urine or bowel habits?
a. No*
b. Daughter - Nurse said everything seemed fine.
14. Are you making normal amount of urine?
a. Not sure*.
15. Do you have any symptoms of urinary tract infection (burning / frequency
of urination)?
a. No*
b. Daughter – per nurse he is making urine.
16. Did you ever have protein or blood in the urine in the past?
a. Daughter - I was told that he had some protein in the urine six
months ago but no blood.
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PROSTATE
ABDOMINAL PAIN
NAUSEA
NEURO
PAIN
Memory/Concentration
17. No changes that I’ve noticed*
18. Do you have abdominal pain or symptoms of acid reflux?
a. No*
19. Do you have nausea?
a. Some nausea today*
b. Daughter – he does not have vomiting or diarrhea though
20. Any weakness in the body?
a. I think I am okay*
b. Daughter – I think he is confused but is able to move all his body
parts without difficulty.
c. Daughter - No neck stiffness, no weakness in arms or legs
21. Are you in any pain?
a. No*
b. Daughter – the nurse said he was not complaining of any pain.
He does have some chronic pain in his knees and hips but it
seems to be in good control with his pain meds.
22. Memory or concentration
a. I think my memory is pretty good and I’m still doing well*
b. Can you recall a recent news story?
i. Hum – I can't recall any recent stories right now.*
c. Who is the president of USA
- ? George Bush*
d. Do you know where you are now?
- ?nursing home*
23. Date, time, location (answer 2 of 3 Incorrectly)
24. When the fellow asks you to remember three objects and then later recall
them, you recall only one of them correctly *
25. How were you before you got the cellulitis – what were you able to do?
a. I was ok – I took of myself – and was busy in my yard.*
b. Daughter - He was independent, still drove to the store, managed
his finances, I only needed to stop by on occasion.
c. Daughter - He has been on blood pressure medication and
medications for his diabetes and everything is fine according to
his doctor. We were told that he does have some decreased
kidney function and his creatinine was 1.7 mg/dL a few months
ago.
26. Appetite?
Eating/Weight Loss
a. Not really hungry. *
b. Daughter - Normally he is a good eater.
27. Any changes in your weight?
a. I don’t know. *
b. Daughter - His weight has been pretty steady for last couple of
years.
Activities of Daily Living
Vision No blurry vision, no double vision, bright lights don’t hurt*
Pertinent Past Med Hx Pertinent Past Medical History: (Given by daughter)
1. High blood pressure – He is currently being treated for high blood
pressure with Lisinopril 40mg a day (has been on it for over 5 years). His
blood pressure has been in good control.
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2. Diabetes – controlled on meds (Glyburide 5 mg per day –over the past 5
years). Blood sugars have been in reasonable control.
3. Most Recent Checkup
a. He sees primary care doctor for routine medical care—He does
not see any specialists.
b. He had a checkup 2 weeks ago (at the time of diagnosis of
cellulitis) with full blood work being done and his kidney function
was slightly reduced (similar to what it was 6 months ago).
4. Why did he get cellulitis?
c. He scratched his leg and got an infection.
5. Thyroid problems: none we know of.
6. Osteoarthritis involving knees and hips.
7. Smoking:
a. No*
8. Alcohol:
a. Drink alcohol occasionally--probably 1-2 drinks per week at the
most.*
9. Any recent medication changes?
Medications
a. Daughter – no recent changes to his medications. The only thing
that is new is the IV antibiotics.
b. He has been in pain from his cellulitis and he may have been
taking more pain meds but I am not sure.
10. Compliance: I take all my medications… the nurse fills my pill box. .. “Did I
take my Blood Pressure Meds today?” (looks confused)
11. Medications
Medications
a. Here’s the list (Provided by daughter)
i. Lisinopril 40 mg once a day (for blood pressure)
ii. Hydrochlorothiazide 25 mg once a day (for blood
pressure)
iii. Amlodipine 10 mg once a day (for blood pressure)
iv. Glyburide 5 mg once a day (for diabetes)
v. Vit D – calcium 1 tab once a day (for bones)
vi. IV Vancomycin 1000 mg twice a day (for cellulitis)
vii. Oxycodone/Acetaminophen 5/325 mg twice a day (for
pain)
viii. Senna 1 tab as needed (for constipation)
ix. Multivitamin 1 tab once a day
Family Medical History
12. Any over the counter medications
d. Daughter - Some herbal medications – he tries some of them. I’m
not sure of the names – but he takes them on occasion.
e. Daughter - No change in prescribed medications in the past few
years (except for the antibiotic now)
f. Daughter - He occasionally takes some herbal medications...Don’t
know what. Not sure about others – perhaps for pain. No known
allergies to medications
Your parents/siblings (Daughter can answer these)
 Father passed away from a heart attack at 76 years of age.
 Mother died at the age of 88 in her sleep.
 2 older brothers who are in “good health”.
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Your Spouse/Children (Daughter can answer these)
 Spouse died 15 years ago because of cancer.
 Your children Mary, John and James are married with their own families.
You have seven grandchildren.
 Your children are in “good health.”
Physical Exam
Social/
Psychosocial Profile
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Will not be performed
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College graduate with a degree in teaching.
Retired from teaching grade school.
Live in the family home by yourself.
Social Support
o I have good friends I was see regularly*
o One of my daughters lives in the area*
Volunteer at the local library and are an avid gardener having won a prize
for your garden locally.
You are well enough off financially that money is not a concern.


Daughter (Mary) can ask the following questions to the fellow:
1. Why is he confused?
2. Why are his legs swollen?
3. Why has my father’s kidney function worsened?
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