SBIRT Standardized Patient Information and Background

From Clinicaltools.com

PLEASE REFER TO http://www.medstudentlearning.com/cynthiaSpoutline which supercedes this page 11-20-2009 MPM

Patient Introduction: Cynthia Stewart, 40 year old white female

Chief Complaint: General checkup due to fatigue and anxiety

History of Present Illness: Cynthia was motivated to get this physical due to fatigue and anxiety, which have slowly built up over the past 3 months. She also is feeling mildy depressed due to financial worries after totaling her car recently, problems at work, and a 5 pound weight gain.

[Medical History, Social History, Family History]

Vital Signs: Height: 5'5", Weight: 145 lbs., Pulse: 80, BP: 130/80

Screening Results: (Available only if ordered) [AUDIT Results]

Physical Examination: (Available only after screening is completed) Nervous demeanor, mild weight excess distributed mostly in abdomen and hips, hands - possible slight tremor, mild diaphoresis, and slightly rapid breathing; otherwise normal.

Lab Results: (Available only if ordered and after screening is completed) [Lab Results]

Other Information for SP Actor:

Offer the following information if asked:

• Car accident: She was driving while intoxicated and was at fault. She says this is the only time she has been caught DWI. With continued questioning she admits she has driven while intoxicated other times but was not caught. She was not injured other than a few bruises.
• Drinking habits: Having a glass of wine when she gets home from work helps alleviate her anxiety. With further questioning, she admits to having another 2 glasses of wine with dinner. Upon further questioning she admits that she sometimes keeps drinking after dinner, sometimes switching to vodka and juice, up to 5 drinks in a night several nights per week. She crossed out daily alcohol use and changed it to 2-5 times per week, because there are some days where she doesn't drink, usually Tuesdays and Wednesdays, although she still has the one drink when she gets home. She is not aware of what the guidelines are for low-risk drinking but admits she knows she is probably past them.
• Fatigue: Her fatigue has gradually increased over the past several months and is not related to exertion. "I just feel low-energy a lot of the time."
• Alcohol use by close friend and family: Her husband joins her for a glass of wine or two before dinner but does not drink otherwise. Father drank excessively but is now sober for 10 years; she says he was a "mean drunk" but does not think he was an alcoholic because he only drank on weekends.
• Headache: She's been getting headaches in the late afternoon lately. In fact, she has one right now.
• Depression and anxiety: She describes her depression as mild and says she was not depressed before "things started going badly" referring to her car accident, problems at work, and arguments with her husband. She has always been an anxious person and started managing it with alcohol after she discovered with her first drink that it eased her anxiety. She has never taken medications for depression and is not interested, saying, "It's not that bad." The anxiety is only under control as long as she drinks; it has become worse in recent months. She is interested in a prescription for it because when she took a friend's XanaxTM, she felt better.
• Relationship: She is happily married, although she and her husband have been fighting more lately. With further questioning, she reluctantly admits it may be related to her drinking. "I'm more likely to say what's on my mind when I've been drinking." They have no children, but she says she is still hoping they will have one some day.
• Sleeping: She has had difficulty sleeping. She cut out drinking all caffeine after noon but this didn't help.
• Social support: She does not have any close friends outside of work. She considers her husband her closest friend. She can also count on her mother and sister to support her.
• Use of other substances, prescription or illicit: Occasionally has taken a XanaxTM given to her by a friend and found it relieves most of the symptoms she's been experiencing. That's why she's here today. She would like a prescription for XanaxTM.
• Tremor: If they ask about the tremor noticed during physical exam, say that it may be because she skipped breakfast and lunch, but with more specific questions or followup questions, she admits that it may happen when she has not had anything to drink for a while.
• Weight gain: She is frustrated to have gained 5 pounds when she has even missed some meals.
• Work-related problems: She has missed work several times per month in recent months and also has come in late several times due to fatigue. Her boss is upset because she has missed several critical staff meetings that she was supposed to lead and has not handled several problems well recently. She attributes her poor work performance to not thinking as clearly as usual.