1 pcl 1 - case 4: session 1 sean o’malley jason pier in dc. (2009). mother and father [electronic...

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PCL 1 - Case 4: Session 1

Sean O’Malley

Jason Pier in DC. (2009). Mother and Father [electronic image]. Retrieved from: http://www.flickr.com/photos/jasonpier/3545398901/

Sean O’MalleyInterview between Sean and his

physician, Dr. Abani MehtaSean O’Malley (SO) visits his physician at the MFA, Dr. Abani Mehta (MD)

MD: Good morning Mr. O’Malley – haven’t seen you in a long time.

SO: Hi Doc.

MD: Please Have a seat over there and we can chat.

SO: Thanks.

MD: So, I see that you haven’t been to the office for several years. You know I see your wife, Alice, every year for her physical. She mentioned that she was going to try to get you to come in. So what brings you in today?

SO: Oh, not much really. Alice thought it was about time I got a checkup.

MD: Did she have any specific concerns?

SO: Alice is a worry-wart. Are you married? You know what it’s like. She says I’m pushing myself too hard . . .

MD: Oh? WomensHealth.gov (2011). Publications for Health Professionals [Online image}. Retrieved from http://womenshealth.gov/publications/health-professionals/

Sean & Alice

Jason Pier in DC. (2009). Mother and Father [electronic image]. Retrieved from: http://www.flickr.com/photos/jasonpier/3545398901/

http://womenshealth.gov/publications/health-professionals/


physician, Dr. Abani MehtaSO: Yeah, the usual aggravations once you hit your fifties – the job, paying endless bills, and dealing with the kids – especially that boy.

MD: So it hasn’t been easy for you lately . . .

SO: It’s been no piece of cake – but nothing I can’t handle, just like I always have.

MD: You’ve got two kids, don’t you? How old are they now?

SO: Julie’s 20 and a junior at Maryland, no problem, great kid. Carl, he’s eighteen now and just started at Maryland as a freshman this past fall. Still a bit wild, that one – doesn’t listen much. Paying bills for both of them has sure turned up the pressure. All this aggravation I’ve gotta put up with – maybe that’s what’s eating at me and making me feel bad . . .

MD: Please go on.

SO: It’s no big deal. When I get aggravated it just makes me feel crummy – no energy, tired all over, nagging heartburn sort of – but I guess laying out two tuitions is enough to do that to anyone.

Sean’s Son, Carl

Graves, Stephanie. (2007). Keg Stand [electronic image]. Retrieved from: http://www.flickr.com/photos/the8rgrl/955839104/

eyewash. (2009). Delta Something-or-Other House [electronic image]. Retrieved from: http://www.flickr.com/photos/eyewash/3899769246/

Julicath (2008) Ma douce Filleule Deli-cat [electronic image]. Retrieved from: http://www.flickr.com/photos/9221141@N02/2977860978/


physician, Dr. Abani MehtaMD: Anything else?

SO: Isn’t that enough, doc ?!

MD: So let me be sure I have this straight. Your wife has been concerned about you. Also, you’re feeling a lot of pressure. Sometimes when you get aggravated you feel bad – tired and you feel some nagging heartburn pain . . .

SO: Yeah, that’s about right, but it’s not pain in the chest, it’s just that sometimes I notice, well, this nagging burning feeling.

MD: Can you tell me more about this nagging, burning feeling.

SO: Well, it doesn’t seem to be related to anything I eat. I’ve got an iron stomach you might say. The more spice the better.

MD: How about after meals or late at night in bed. Does the burning act up then?

SO: Not really, I guess I notice it mostly during the day. When I hit the sack at night, I’m out like a light.

MD: OK, does this discomfort get very intense?

Robert the Noid. (2007). A Good Place to Study [electronic image]. Retrieved from:

http://www.flickr.com/photos/herbarium_gnome/1992013924/in/photostream/

Sean’s Daughter, Julie


physician, Dr. Abani MehtaSO: Nah, nothing I can’t put up with.

MD: I see, so when do you notice this pain?

SO: I said before I don’t get no pain.

MD: I’m sorry, I meant the nagging and burning. When does it seem to act up?

SO: Well, as I said, the never-ending money problems usually get it going. Like when I gotta do those monthly bills late at night. That’s one big aggravation.

MD: There’s nothing like kids at college to keep you in the hole. Anything else?

SO: You mean that causes the nagging?

MD: Uh huh.

SO: Well I guess I’m probably getting old. In the morning I gotta walk the dog before heading off to the garage. This time of year is still pitch black, cold, and the wind’s coming right up the block. By the time I get to the end of the driveway I usually get the nagging but I usually ignore it and get on to the job.

MD: I see. Where exactly do you feel this discomfort?


physician, Dr. Abani Mehta

SO: Oh, sort of here in the throat.

MD: Do you notice it anywhere else?

SO: What do ya mean?

MD: Does the pain, I mean the nagging, move anywhere else?

SO: Well sometimes when it gets a bit intense, it might move up under my jaw.

MD: How long does it usually last?

SO: Maybe a few minutes, I guess. I usually ignore it and it disappears before I know it.

MD: OK, well do you notice that feeling any other times during the day?

SO: Not too much, Sometimes when I’m driving the train, maybe. Between the tight schedule and the people trying to jam on the train at rush hour, that’ll get me steamed and all the aggravation is enough to give anyone heartburn. That’s why I keep a roll of TUMS handy. One or two and it’s gone.

MD: Has anyone in the past ever told you that you have any stomach or gastrointestinal problems? Or needed liquid antacids?


physician, Dr. Abani MehtaSO: Nah, but some years back when I had a check up for the job, a doc told me I might have some kinda hernia problem.

MD: Did he say a hiatal hernia?

SO: Yeah, maybe. He said I might want to get one of those x-ray tests where you drink that liquid stuff or something. Since I felt okay, especially after cutting back on my drinking, I never bothered to do anything about it again.

MD: How about alcohol? Are you much of a drinker nowadays?

SO: Naw, nothing like the old days. Just a few beers on the weekend. Never during the week and never when I’m on the job – have to be alert when I’m on the train.

MD: Good enough then. You were talking about your work before. How long have you been working for Metro?

SO: Seems like forever. This spring will make 27 years. It’s the only place I’ve worked since I got out of the army in ‘84. Driving that train everyday has worn me out. And then there are those rush hour shifts with everyone trying to cram themselves unto the train. I was hoping there might be an opening in the office for a supervisor position but they’ve cut back and there’s no opening in sight. Looks like I’m stuck driving the train . . .


physician, Dr. Abani MehtaMD: Sounds like that train must give you a lot of stress.

SO: You’re telling me! Sometimes if I drive a long stretch and I have to deal with those pushy rush-hour commuters, I can get a doozy of a headache. Seems to happen more in winter – maybe cause everyone is crabbier in the cold. Then there’s that damned water cooler - that’s always a royal pain!

MD: What’s that about?

SO: You see we have this water cooler in our break room and every week I have to lug in a new bottle and those things weigh about 40 pounds. I’m outta shape so lifting that thing sometimes makes me feel that nag in my throat, but it doesn’t last long.

MD: Mm. Anything else bring it on? Like exercise? Do you have any time for leisure activities?

SO: Exercise? Me?! Does watching the Redskins count? I’m mostly into spectator sports. As I said before, I walk the dog most mornings but that only takes five or ten minutes. On the weekends, I’ll mow the lawn, but nowadays I gotta take my time. Lately I got this arthritis condition in my left shoulder probably from an old high school football injury. Just another part of me falling apart with getting older. When I try to lift my left arm I can barely reach above my head. Then when I push the mower sometimes the shoulder really acts up and I might even notice that heartburn. If I rest a moment, the shoulder must loosen up or something, (cont.)


physician, Dr. Abani MehtaSO (cont.): and I can finish the job without any problem. Of course, that college boy of mine is supposed to take care of the lawn. But come the weekends in the summer, he sleeps all morning and then disappears with his buddies. Anyway, as you can see I’m not an exercise nut.

MD: I got the picture – does that shoulder of yours act up any other time?

SO: Once in a while. Just when I overdo it. It’s sensitive to the cold weather and sometimes when I’m at work I’ll notice it. By the end of the day, when I’m doing the brakes and accelerator, the old shoulder will start to ache. A couple aspirin, and I’m okay.

MD: How often do you try aspirin?

SO: Well, I keep a bottle on the train with me, as well as back at the house. On a bad day, maybe I’ll take 6 to 8 pills.

MD: Are you taking any medications, other than the aspirin?

SO: Just some Ben Gay, but I can’t tell if that does much.

MD: OK. Now, do you have a history of any other medical problems?

SO: No, I’ve been pretty healthy so far. Only went to the hospital when I was a kid to get my tonsils out. I’ve been able to avoid doctors these past years.


physician, Dr. Abani MehtaMD: Nothing else, like diabetes or high blood pressure?

SO: In me? Nope.

MD: How about in your family? Your parents?

SO: Oh yeah, my mother, she had a sugar problem I think when she was in her seventies. And my dad, he wasn’t diabetic but he had high blood pressure as long as I can remember. Not much they could do about it in those days.

MD: Are either of your parents still alive?

SO: Nope, my father died a long while back when he was about 53. My mother just passed on two years ago when she was almost 80.

MD: Do you know what happened to your dad?

SO: Not really. I just remember he went off to work one day and collapsed in the middle of the shop. He never knew what hit him.

MD: Did the doctors tell you what they thought happened?

SO: They weren’t sure.


physician, Dr. Abani MehtaMD: Did they say it might be a heart problem?

SO: Well, I guess they did say my dad might have had a weak heart, maybe because of his smoking, but otherwise no one else in my family had any heart problems as far as I heard.

MD: Do you smoke cigarettes?

SO: I used to smoke 2-3 packs a day but the coughing would rack my chest. So I quit for good about 2 years ago.

MD: That’s great! Do you still cough at times?

SO: Oh yeah, but not the coughing fits I had in the past.

MD: Do you have a history of any lung illnesses, like pneumonia, tuberculosis, coughing up blood?

SO: Nope, nothing like that.

MD: Has anyone ever told you that you have high cholesterol?

SO: Nope, I don’t think I ever got it checked.


physician, Dr. Abani MehtaMD: Now I noticed your weight on the scale today is 224 pounds. Is that your usual weight?

SO: Pretty much. Years ago, before I got married, I was around 180, 185. But you know, you get older, new responsibilities, and so forth – I’ve sort of expanded a bit, doc.

MD: Have you tried to lose a few pounds?

SO: Well both my wife and I are a bit on the heavy side as you know. She is always saying that the both of us gotta lose 20 pounds, so she is always trying us on some new fad diet. Once in a while I lose 5 pounds but it always comes right back. The big problem was when I quit smoking – I started eating everything in sight and after 4 weeks I had put on 15 pounds. Never was able to lose that again.

MD: What kind of diet do you have now?

SO: Nothing special, I’m your typical meat and potatoes kind of guy.

MD: Do you try to avoid fat in your diet?

SO: Nah, the wife and I, we don’t have time for any fancy cooking – unless she’s on one of her diet kicks, but those don’t last too long.

MD: How are you and Alice doing? She seemed concerned about you when I saw her.


physician, Dr. Abani MehtaSO: Well doc, I guess with work, the kids, expenses – I can be a pain sometimes when I’m home. I’m sure I give Alice more trouble than she deserves.

MD: So you two are doing OK as you head into your 50s?

SO: Well, I guess we’re both going through the change in life. She misses the kids, especially Carl – that ‘empty nest syndrome’ I guess. But she’s volunteering at the YMCA, teaching swimming to some handicapped kids. She’s thinking about working to help out with the bills, but I’d rather she just did the stuff at the ‘Y’. I’ve always provided for us and I don’t see why that should change now.

MD: How about your sexual relations?

SO: Our sex life? That’s okay I guess – we both like to ‘get busy’ once in a while, if you know what I mean. But I gotta take it slow nowadays. I’m not in as good of shape – get short of breath sometimes, maybe even a little heartburn, but I don’t let her know.

MD: I understand. Well, maybe we can figure out a way to get you back in shape. Let’s go into the examining room next door where I can take your blood pressure and do a thorough physical exam. Then, maybe I can give you some suggestions.

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Sean O’MalleyBackground

Go to Problem List

Go to Clinical Notes

Go to Clinical Notes and Fill Out the History That You Have Learnt

Thus Far.

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Go to Problem ListGo to Clinical Notes

Distribute and Read Handout 1:

Background

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Go to Problem ListGo to Clinical Notes

Handout 1: Background – Take Away Points

• Middle-aged, working class male.

• Father died suddenly at 53.

• Wife makes a lot of the health-care decisions.

• He and Alice have traditional roles at home.

• Ex-smoker / minimal exercise.

• Complicated relationship with children – wants to create opportunities for his children that he never had.

Sean O’MalleyEKG and Results of the Exercise Treadmill Test

Mr. O’Malley underwent a screening study for CAD with an exercise treadmill test .He was shown this video prior to consenting for the test . . .

Stress Test Video

http://www.youtube.com/watch?v=Gi1aNFJmXoI&feature=related

Sean O’MalleyEKG and Results of the Exercise Treadmill Test

Lead V4 at rest (top) and after 6 METS of exercise (bottom). He has a burning sensation in his throat and 3 mm (0.3 mV) of horizontal ST-segment depression, at a heart rate of 145 beats per min and systolic BP 150 mmHg. His test is "positive" for ischemia.

LIPID RESULTS:The patient had a lipid profile drawn at the end of the first office visit as an addition to his CAD risk profile. The total cholesterol is high (275mg%) with a high LDL subfraction (195mg%) but normal HDL (45mg%) and triglycerides (195mg%).

N.A. (N.D.) Stress induced Electrocardiogram in a patient of Angina Pectoris[electronic image].

Retrieved from: http://manbir-online.com/cardiac/ecg_stress-test-

2.htm

Sean O’MalleyReview of Case History (Part 2)

Distribute and Read Handout 2: Review of Case History

(Part 2)


Handout 2: Review of Case History (Part 2) – Take Away Points:

• Positive exercise test.

• Worried about job security.

• Taking Atenolol, baby Aspirin, Nitroglycerin.

• Receives dietary advice.

• Coronary angiogram recommended.


Cardiac Cath Video

http://www.youtube.com/watch?v=3Z2DaU0GBAE&feature=related



Problem List

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Learning Objectives

Go to Session 2: Wrap up


Go to Session 2: Management

Go to Session 3: Management


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Sean O’MalleySession 1 Wrap Up

NEXT SESSION:

Student Presentations:• Students will prepare presentations based on the

outcomes/problems that were identified during class.

• Also assign psychosocial roles to be covered during the third session (each of these will be given a handout to guide their research):• Health Psychologist• Consultation Psychiatrist (personality and athersclerotic

cardiovascular disease)• Consultation Psychiatrist (stress and coping)• Primary Care Physician/Nutritionist


Go to Problem List

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NEXT SESSION:

Required Reading (available on Blackboard) Fortunato, D.J. & Ferri, F. F. (2012). Angina Pectoris. In: Ferri’s

Clinical Advisor (1st ed). Elsevier.

Supplemental Reading: (available on Blackboard) Boden, William. (2011). Chapter 71: Angina Pectoris and

Stable Ischemic Heart Disease. In: Cecil’s Medicine (24th ed). Elsevier.

.


Go to Problem List

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End of Session 1

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Sean O’Malley

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Sean O’MalleyManagement of Session

2

Presentations: Learning objectives identified by the group

Review of Case History (Part 3)

Phone Conversation between Dr. Mehta and Mr. O’Malley

Go to Problem List Go to Clinical Notes


Distribute and Read Handout 3: Review of Case History

(Part 3)


Handout 3: Review of Case History (Part 3) – Take Away Points:

• Chest pain symptoms resolved.

• Unhappy with dietary changes.

• Worried about job security.

• Experiencing sexual dysfunction.

• Minimizing severity of condition.

Sean O’MalleyPhone conversation between Sean and Dr. Mehta

• Alice, worried about Sean’s decision to stop taking his medication, calls Dr. Mehta to tell her what’s going on. At first Dr. Mehta is angry (“Doesn’t he know that this is a serious situation? How can he just stop his meds? Doesn’t he think I’m serious?”) Alice says that Sean is just scared, and that he is just really worried about work. She asks if Dr. Mehta would call her husband and talk to him – she does . . .

Dr. Mehta (MD) and Sean O’Malley (SO) talk on the phone

MD: Hello, Mr. O’Malley?

SO: Hello doc. You found me out – I suppose Alice told you?

MD: Well, I did talk to her yesterday, but I was already aware that you had cancelled your follow-up appointments with me – plus Alice told me that you stopped taking your medications. Is that really true?! (incredulous and accusatory)

SO: Yeah doc, I did – those pills were making me ‘limp’ – if you know what I mean!

MD: Yes, but did they help the chest burning?

SO: I think so, at least it seemed to go away after I started taking them.


MD: And you still stopped them anyway?! You know that could be pretty dangerous for you, Mr. O’Malley?

SO: Well, they were messing up my sleep and with driving the train and all, I didn’t think that was too safe either, doc!

MD: Well, maybe you’re right. Would you be willing to try another type of pill, one that might do the same positive things but without the side-effects you seemed to be experiencing?

SO: I might, if you think it’s really necessary.

MD: What about the cardiac rehab program and coming back to see me?

SO: I don’t know about all that – I don’t want the folks at work to think I’m really sick.MD: Why’s that, Mr. O’Malley?

SO: Because this might be the excuse they need to replace me with some younger, cheaper driver!

MD: Mr. O’Malley, you don’t need to worry about that, I already spoke to your supervisor. He called to see if you were alright after he got my note. I told him you would continue to work as long as you were on medication and doing alright. He didn’t seem to have any problem with that.


SO: (relieved) Is that right, doc? Well, OK then. I’ll come over and see what else you got to keep me going. And thanks – Alice was right about you, she said you were the best!

MD: See you tomorrow at 3pm, OK?

SO: Sounds good – see you then.

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Sean O’MalleyOverview of Learning

Objectives for Students

(These Will Not Be Tested as Part of PCL)

Clinical Problem Solving Practice using a differential diagnosis for chest pain, keeping in

mind both common but also more serious “do not miss” conditions. Identify appropriate and cost-effective use of medical resources. Basic and Clinical Sciences Recognize normal physiology of the heart, ischemia, and how it

occurs, and how ischemia effects heart function. List the factors producing atherosclerosis? Interpret the abnormalities of cholesterol tests and lipid profile. Identify therapeutic (tertiary prevention) strategies for angina and

list effects and side-effects of anti-anginal medication.


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Sean O’MalleyOverview of Learning

Objectives for Students

(These Will Be Tested as Part of PCL)

Psychosocial, Behavioral, and Developmental Issues List the normal middle-adulthood developmental tasks Discuss stress and coping responses to illness—ways in which

people react to illness and the contributors to such behaviors. Describe the theories of motivating behavior change with

application to obesity (motivational interviewing).

Informatics Practice selection and evaluation of information resources to

support PCL research. Identify resources available to locate drug information. Locate and utilize clinical calculators to compute body mass

index and Framingham score.

Go to

Clinical NotesGo to Problem List

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NEXT SESSION:

Psychosocial Presentations (Distribute Handouts 7-10)• Health Psychologist• Consultation Psychiatrist (personality and atherosclerotic


Distribute handout 6: Biopsychosocial All Students Guide (ALL)

Distribute handouts 4 & 5: Food Diary and Exercise Diary (ALL) Volunteer to make healthy snack for next week

Presentations: Practice USMLE Questions

Feedback & Discussion


Go to Problem List

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NEXT SESSION:

Required Psychosocial Readings:Sahler and Carr – Behavioral Sciences and Healthcare:• Motivational Interviewing (pp. 70-71)• Defense Mechanisms (pp. 76-77)• Adult Years (chap. 13; pp.101-108)• Obesity (chap. 20; pp. 159-162)


Go to Problem List

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End of Session 2

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Sean O’Malley

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Sean O’MalleyManagement of Session

3

Psychosocial Presentations• Health Psychologist• Consultation Psychiatrist (personality and atherosclerotic


Discuss Food Diary and Exercise Diary Healthy snack

Practice USMLE Questions

Feedback & Review Case Objectives: Were all of the learning objectives covered?


Go to Problem List

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Sean O’MalleySample Questions from USMLE Step 1 Review

1. A 62-year old African American man presents with exercise-induced angina. His serum cholesterol is 277 mg/dL (normal <200), LDL is 157 (normal <157), HDL is 43 (normal > 35) and triglycerides are 170 (normal <150). His BMI is 34 and his coronary risk ratio is 6.84 (normal <5). On cardiac catheterization there is occlusion of the left anterior descending and the origin of the right coronary artery. The disease process is initiated by which of the following:

A. Proliferation of smooth muscle cellsB. Formation of an intimal plaqueC. Attraction of platelets to collagen microfibrilsD. Adventitial proliferationE. Injury to the endothelium

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E. Injury to the Endothelium

The site at which coronary arteries become occluded are : first, at the left anterior descending (thus affecting both ventricles anteriorly); second, at the origin of the right coronary artery affecting both the right atrium and ventricle and disrupting cardiac rhythm; and third, the circumflex branch (affecting both left atria and ventricle). Atherosclerosis is initiated by damage to the endothelial cells, which exposes the subjacent connective tissue (subendothelium). The loss of the antithrombogenic endothelium results in aggregation of platelets. Atherosclerosis is one form of arteriosclerosis (hardening of the arteries) that involves deposition of fatty material primarily in the walls of the conducting arteries. The intimate and media become infiltrated with lipid. Intimal thickening occurs through the addition f collagen and elastin with an abnormal pattern of elastin cross-linking. Platelets release mitogenic substances that stimulate proliferation of smooth muscle cells. The thickening of the intima is also called an atheromatous plaque and worsens with repeated damage to the endothelium. It is most dangerous in small vessels, particularly the coronary arteries, where occlusion can result in a myocardial infarction. Atherosclerotic plaques also lead to thrombi and aneurysms. (2008) . Clinical vignettes for the USMLE Step I. New York: McGraw-Hill.

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2. A 56 year old male was admitted to the hospital with angina and diaphoresis. A myocardial infarction is suspected, and a 12-lead electrocardiogram (ECG) is ordered. The ECG is most effective in detecting disease in which of the following?

A. Ventricular contractilityB. Mean blood pressureC. Total peripheral resistanceD. Ejection fractionE. Coronary blood flow

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E. Coronary Blood Flow

Abnormalities in coronary blood flow resulting in ischemia of the ventricular muscle will lead to a current of injury, which is reflected as an upward or downward shift in the ST segment of the ECG recording. The electrical activity of the heart does not reflect changes in ventricular contractility, blood pressure, ejection fraction, or total peripheral resistance, although all of these can be altered by changes in coronary blood flow. (2008) . Clinical vignettes for the USMLE Step I. New York: McGraw-Hill.

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3. Mr. D has been non-adherent with his treatment regime. His physician decides to make use of goal-setting to increase his patient’s adherence in the future. Published guidelines and clinical experience in the use of “goal-setting” to increase patient adherence suggests that the technique will be most effective when:

A. Goals are defined by the physician to insure appropriate priorities

B. Goals are graduated to maximize success experiencesC. Goals are maintained consistently and may not be alteredD. Goals are sufficiently broad to allow the patient leeway in

meeting themE. Patients seek to “shoot for the moon” and achieve maximal

results

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B. Goals are graduated to maximize success experiences.

No one likes failure. Success in reaching a goal can, by itself, be reinforcing. Making goals incremental makes each step more attainable and helps to keep the patient motivated and on track. Goals that are too broad are ambiguous. Goals set by the provider without patient input may ignore difficulties of which the physician is unaware and typically do not have the level of “buy in” from the patient needed for success. “Shooting for the moon” may feel great if the moon is actually hit, but the chances of failure are too great, and the goal just looks unattainable (and, therefore, non-motivating) to the patient. Goals must be flexible so they can be altered as circumstances change. Sahler, O.J.Z. and Carr, J.E. (2007). The Behavioral Sciences and Health Care. Cambridge, Massachusetts: Hogrefe.

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Feedback:o Give feedback to the Student Case Leader

o Did students accomplish all of the objectives? Teamwork? What worked? What did not work?

Distribute Entire BioPsychoSocial Packet to all Students

Next Time: the case of Jason Goodman! Choose a Student to be the Case Leader for Case V


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End of Session 3

CC: (Chief Complaint/Concern):

HPI: (History of Present Illness):

PMH: (Past Medical History):

Clinical Notes:

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Past Surgical History:

FH: (Family History):

Medications:

Allergies:

Clinical Notes:

Past Medical History:

Clinical Notes:

Assessment & Plan:

Labs: Review of Systems:

Physical Exam:

1 pcl 1 - case 4: session 1 sean o’malley jason pier in dc. (2009). mother and father [electronic...

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