Case examples and scoring sheets

Three cases are presented to illustrate the rationale of using the INTERMED in clinical practice. After a short description of the information available at referral or admission and the information obtained from the patient, the scoring of the INTERMED is provided. The readers are referred to the description of the clinical anchor points in Appendix 1 and are invited to perform the scoring and check their results using the proposed scoring presented at the end of this Appendix. Finally, for each case a summarized case vignette, as used for multidisciplinary case conferences, referral, or discharge letters, is provided, followed by a proposal for a treatment plan.

Patient 1: admission for diarrhea and some other complications

Reason for admission

The patient, a 27-year-old woman, was admitted to the department of gastroenterology for the evaluation of diarrhea. There are several reasons for the admission. First, in the last month extensive diagnostic evaluations have been made, but a final diagnosis is still to be determined. Second, the patient's condition has declined, and she has lost about 10 kg in the last month. Third, the patient has informed her doctor that she is almost incapable of doing anything at home. She has suffered from systemic lupus erythematosus (SLE) for about 4 years and is being treated by a nephrolo-gist, because her kidneys were the primary location of the disease. There is a gradual decline of the kidney function. A relationship between the diarrhea and the SLE is expected but has not yet been confirmed.

Additional information

During the admission the following information is obtained. Although the patient is silent during the admission process, she starts to cry when the nurse suggests that she must have been in an awful situation, being so ill at home. She replies, "How would you feel? I have been ill ever since I was married!'' She then tells the nurse that in the beginning the complaints were vague. One doctor had suggested the stress of the marriage as a cause. Later, another doctor suggested the possibility of chronic fatigue. She then visited a neurologist, because a friend suggested that she might suffer from multiple sclerosis. The neurologist, after carefully listening and reviewing the earlier reports, referred her to an internist, suggesting a rheumatic disease. At first the internists, although they found abnormalities in her blood, could not find a diagnosis. Finally the diagnosis of systemic lupus erythema-tosus was made, and treatment with corticosteroids and another drug was started, because her kidneys did not function well. Although the doctors were satisfied with the results, and she felt a little better, she hated the bloated look induced by the medication. Therefore, in the beginning, she stopped her medication a few times; now she still has resistance and doubts but basically complies with what doctors prescribe.

In the course of their marriage it also became clear that she was not able to get pregnant. She therefore visited an infertility clinic about 2 years ago. After all kinds of investigations the doctors concluded that, because of her illness, she could not be admitted to a fertilization program; her chances of becoming pregnant were regarded as minimal. Although she asked the doctors to discuss this issue with her nephrologist, no action was taken, and she was afraid of being perceived as difficult and did not ask again. As a consequence of the diagnostic confusion in the past she does not really trust doctors, although she trusts her nephrologist and is inclined to follow his advice.

From being a cheerful adolescent she gradually became a person who had a negative self image: that she was not a good partner for her husband, could not have children, and was always tired. The information received about 2 years ago that she was not able to bear a child induced very negative feelings, and she attempted suicide using her husband's painkillers. She was unsuccessful, and she did not inform anyone of this attempt.

The relation with her husband deteriorated during the last 5 years, because he could not accept the idea of not having children. Consequently they often had quarrels and even fights. He even hit her a few times. The family did not understand her staying with her husband and turned away. The couple has almost no friends. The patient did not have many interests but succeeded getting a volunteer job preparing drinks in a daycare center for children. For last month she has not been able to perform at all. The diarrhea made her feel weak. Her mood declined; her thoughts were focused on the course her life had taken, and she often thought, ''Why do I take all this medication?'' Often she thought she would be better off dead.

Scoring case 1

The reader is invited to score this case using scoring sheet provided in Fig. 6 and the clinical anchor points described in Appendix 1 and to check the results as presented at the end of Appendix 3.

Case vignette

The patient is a 27-year-old woman who was admitted to the department of gastroenterology for diarrhea, because this condition represents a diagnostic problem and because the patient feels weak and is not able to care for herself. Several years ago, she was diagnosed as having SLE with a kidney location, but several referrals and quite some time were required to obtain the diagnosis. Patient is living in her own apartment with her husband. Their relation is complicated, because she is always ill and is not able to have children. Her condition has resulted in quarrels and fights. They almost divorced. Because of her illness, the patient has never been able to work, but she did perform some volunteer work. There are almost no social contacts. She has negative feelings about herself. Sometime ago, when she realized she

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would never be able to have children, she tried to commit suicide using medication. During recent years she had felt a little blue most of the time. Currently, she admits to feeling depressed and to thoughts that she would better be dead. A nephrologist, a gastroenterologist, and a gynecologist have treated the patient. The first two are her current caretakers. The patient's respect for doctors suffered when several doctors involved in the assessment of her complaints provided different but seemingly inappropriate answers. She trusts her current physicians, but her general trust in doctors and what they can do is diminished. Basically, the patient is compliant, although there is some resistance because of the side effects of the medication and the deterioration of her situation.

Treatment plan

Biologic. This patient suffers from a complex medical illness complicated by new symptoms of previously unclear origin. The available diagnostic procedures should be re-evaluated. Because diarrhea might also be a symptom of a psychiatric disorder (anxiety and depression), this could be an alternative explanation. Because the patient is weak and has suffered weight loss, a dietician and a physiotherapist should be consulted.

Psychologic. The patient is psychologically vulnerable. Most probably she suffers from a depressive disorder, which should be confirmed by a psychiatric consultation. This consultation is specifically necessary, because she has a history with a suicide attempt. The loss of vitality may be caused by the physical illness, the infertility, depression, a bad relationship with her partner, and withdrawal from family members. Another contributing etiologic factor might be the medication used for the SLE. A specific focus therefore should be treatment of the depression and assurance of compliance. Psychiatric medication should be adjusted to her physical illness. Tricyclic anti-depressants might have an advantage over selective serotonin reuptake inhibitors because of their specific effects on the gut function. Furthermore the ward staff should be instructed in how to approach the patient, including her physical activity training. In addition involvement of the partner in the psychologic treatment of the patient should be considered.

Social. As part of the psychiatric assessment and treatment, interventions should be considered to counteract her social vulnerability. Depending on the outcome of the physical evaluation, the effects of the initiated treatment, and the results of the psychiatric assessment, a postdischarge plan should be made.

Organization of care. As indicated by the high total score (35), this case is highly complex with interactions between severe physical and psychiatric illness. Coordination between the different providers of care is required. A multidisciplinary case conference is necessary as soon as the results of the psychiatric, dietarian, and physiotherapy consultations are available. During the patient's hospital stay, a coordinator of care should be considered. When the patient is discharged to her home, postdischarge coordination of care is required.

Patient 2: evaluation of drain for normal-pressure hydrocephalus

Reason for admission

The patient is a 72-year-old man. He is admitted to the hospital for the evaluation of his ventriculo-peritoneal drain on request of the general practitioner after telephone consultation with the patient's neurosurgeon. The neurosurgeon evaluated the patient in the emergency room and decided there that an admission is necessary because there are clear signs of drain dysfunction. Patient was admitted 2 years ago for the placement of a drain for a normal-pressure hydrocephalus (NPH). The etiology of the NPH is most probably traumatic. A year before the patient had a bicycle accident in which he fractured a leg and had a cerebral contusion.

Additional information

At the end of the first day of admission the neurosurgeon and the nurse who admitted the patient collected the following information from the patient's wife. Before the operation he always had good physical health and has almost never seen a doctor. He had worked as the chief of financial administration in a firm with 100 employees. He had not been an easygoing man, because he was rather strict and stubborn, which resulted in conflicts and job changes. Retirement had been difficult for him because he missed his work. Through a neighbor he became a member of a bridge club. It was there that he had started to drink. The amount of his drinking had made his wife and also members of the club somewhat concerned. His accident occurred after one of the nights at the club.

After his hospitalization it had taken intensive work by his wife to get him in good shape again. Over the course of a year after coming home, he gradually developed walking difficulties, urinary incontinence, and memory problems. In addition the patient became easily irritated and difficult for his wife to manage. The general practitioner who was consulted suggested that the problems were all related to alcohol and advised the patient to stop his alcohol intake. Because the same general practitioner had missed the diagnosis of rheumatoid arthritis in the patient's wife, saying that her complaints were stress related, the wife had been dissatisfied with his suggestion and consulted another general practitioner with the patient. This general practitioner referred the patient to a neurologist to evaluate the effects of the cranial trauma.

The neurologist diagnosed an NPH and referred the patient to the neurosurgeon, who confirmed the NPH and recommended surgery. The admission for the surgery was associated with problems. The patient had been confused after being admitted and after the operation. There were signs of a delirium with as etiologic factors the operation, but alcohol withdrawal probably was involved as well. After about 2 weeks both physical and psychologic functions improved, and the patient was discharged to his home. The alcohol abuse had not been addressed further.

The last visit to the neurosurgeon had been about 6 months ago. During that visit the patient had to wait about an hour and concluded that this was his last visit, because he perceived the surgeon as passive and not doing much too help him. He had also stopped his visits to the club. The couple does not have offspring. There is telephone contact with family members at anniversaries.

The current period of deterioration started about 2 weeks ago. His wife informed the general practitioner that there were again signs comparable with the period before the NPH operation: walking became more difficult, and the patient became incontinent again. In addition, the patient, who was always difficult and quickly irritated, became even more difficult. He had threatened his wife about involving doctors and was increasingly drinking more. In the last few days he seemed to display a general sense of confusion, stopped drinking, could not remember what happened during the day, and was disoriented in time. He had been too ill to actively resist the ambulance personnel who came to bring him to the hospital. His wife informed the neurosurgeon that, whatever his findings and the results of surgery were, she would not be inclined to have him as a patient at home because she was afraid of him and unable to handle him, particularly because her rheumatoid arthritis had deteriorated. During the first day of admission the patient became irritated and threatened the nurses. He demanded to be released, saying he would otherwise summon the police. It was evident that he was disoriented in time and place and did not quite understand what was going on. Antipsy-chotic medication had been necessary to restrain him.

Scoring case 2

The reader is invited to score this case using the scoring sheet provided in Fig. 7 and clinical anchor points described in Appendix 1 and to check the results as presented at the end of Appendix 3.

Case vignette

The patient is a 72-year-old man admitted through an emergency procedure to the department of neurosurgery for the evaluation of the functioning of a drain for an earlier diagnosed and operated NPH. The reasons for doubts about its function were recent behavioral changes. The surgeon is quite confident about the diagnosis. Except for the NPH, which is trauma related, patient does not suffer from other physical diseases. The initial diagnosis of NPH was somewhat delayed. The patient is living with his wife, but she is unable to manage him in his current state and refuses to have him back at home. The couple does not have children, and their social contacts have diminished in the last years. Before retirement the patient was

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Fig. 7. Scoring sheet for Case 2.

Fig. 7. Scoring sheet for Case 2.

a financial administrator and later had some contacts in the bridge club. Because he was not an easygoing man, there were often conflicts at home. He was quickly irritated and started to drink increasingly at the bridge club. The patient experienced delirium during his earlier admission. In the days before and at this admission, the patient was confused and agitated. During the last years, the patient had some difficult contacts with health care providers. He had been admitted for the surgery but later stopped the contacts with the neurosurgeon. Currently only his general practitioner sees him. The patient's trust in doctors is reduced because of the course of the diagnostic process for the NPH, and his compliance with medical recommendations is impaired.

Treatment plan

Biologic. The patient suffers from a chronic physical condition that might be complicated by serious physical impairment. His current condition requires treatment of alcohol withdrawal, an evaluation of the function of the drain, and probably an operation. The course of the physical illness will have direct consequences for the current and long-term psychologic functioning of the patient.

Psychologic. The patient has indications of a serious psychiatric disturbance, including behavioral risks, with indications for immediate treatment. The patient is at risk of having or developing delirium caused by the NPH and alcohol abuse/withdrawal. Moreover there may be chronic cognitive impairment compatible with the development of a dementia. Because the patient is confused, he is not able to comply; this inability should be addressed actively to avoid further deterioration. Consequently the compliance should be enhanced by external factors, such as a stringent and probably parenteral medication regime. In addition, the prevention of injury and the instruction of family and staff about how to approach the patient according to the principles of delirium management is necessary. Interventions to prevent further psychologic deterioration during hospitalization are required. A long-term strategy is indicated to monitor and eventually ameliorate the cognitive capacity and the consequences of his character change.

Social. Rehabilitation through a nursing home should be considered, but placement in a nursing home might be the final outcome. Therefore additional information on the patient's housing situation and his wife's functional capacity is needed.

Organization of care. Because there is a combination of disturbances (high INTERMED score: 35) that interact with each other, and because of the patient's age, health care should provided by a multidisciplinary team including, in addition to the basic neurosurgery team, a geriatrician or a psychiatrist, depending on local policy, and a social worker. After emergency treatment for the withdrawal and the delirium, a case conference should be organized to plan long-term care and to assign a case manager. This planning is dependent upon the outcome of the neurosurgical/geriatric/psychiat-ric assessment and the information collected by the social worker. Preferably the care coordinator should be a geriatric nurse.

Patient 3: headache after an accident Reason for visit

The patient is a 27-year-old man from Morocco who lives in Switzerland. He presents himself to the general practitioner, who has known him for a couple of years. He has experienced a good health, except for flu 2 years ago. Even though the patient's immigration is recent, his mastery of language and pronunciation are quite good. About 6 months ago the patient stayed 1 night on the department of neurology for the evaluation of the effects of a head trauma as result of an accident: quite unexpectedly, while riding a bicycle, he had been struck by a car. In addition to the commotio cerebri, he had a broken wrist, which recovered without functional restrictions. Four weeks after the accident, a neurologist saw the patient. His main complaints were difficulties with his capacity to concentrate and memorize.

The neurologist informed the general practitioner that the electroenceph-alograph did not show irregularities, and the neuropsychologic investigation also was normal except for unspecific and usual problems with concentration after a light head injury. The patient informed the general practitioner that ever since the accident there had been something wrong in his head. Although he has tried to explain this to the neurologist, the neurologist did not provide a clear answer, as far as the patient understood. The patient believes that the neurologist considered that his complaints were caused by nervousness. He is not satisfied, because his complaints do cause him concern. Because the patient presented the problem as an emergency and because the problem seemed complex, the patient was requested to return in the afternoon for a more intensive evaluation.

Additional information

In the afternoon the patient presented himself with his wife. He reports having frequent headaches and being tired without any effort; as a result, he does not feel he is able to work. In addition he has problems with his memory and is easily irritated. After the accident he tried once to return to his job, but this attempt failed because of the headaches. As a result he had a dispute with his company's medical officer. The patient informs the general practitioner that he is quite concerned about his health and that his health concerns preoccupy him most of the day. During the last month he has not slept well, and he feels tense, although he is not anxious. In addition, the patient recently lost some weight. As a Muslim, he does not smoke or drink alcohol. Compared with earlier visits, the general practitioner gets a different impression of the patient. The patient's mood seems low, and he is tense. The presentation of his story is clear and not confused. Physical examination, including the neurologic examination, does not provide evidence of a physical illness.

His wife provides the following information: She met him while on holiday in Morocco. She works in a flower shop and is in good physical health. According to his wife, their relationship has been increasingly tense in the last month. She has known him as an optimistic man who seemed to be quite capable of handling the problems of the last years. They had some friends who they saw on a regular basis, and they were considering having children. Although some friends had warned her about the problems of marrying a foreigner from such a different culture, she had been impressed with how he had adjusted to his new situation. There has been quite a change since the accident, however. The patient stays at home almost all day and does not do much, although cooking and reading always had his interest. He had become increasingly difficult and irritable. As a result, rather unexpectedly, their relationship had become difficult. After a quarrel last week over something unremarkable, she stayed for a night with her parents.

The patient was born in Casablanca. He comes from a stable family. He has two brothers who live in Europe. His parents died about a year ago, his mother after a short period of illness probably caused by a brain tumor, and his father as a result of a car accident. In Europe he has not been able to reach his former professional level as an electronic technician. At the time of the accident he was working as supervisor of a crew in a cleaning company. Recently, an employee has been fired for making discriminatory remarks to foreign colleagues, including the patient.

Scoring case 3

The reader is invited to score this case using scoring sheet provided in Fig. 8 and the clinical anchor points described in Appendix 1 and to check the results as presented at the end of Appendix 3.

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Fig. 8. Scoring sheet for Case 3.

Fig. 8. Scoring sheet for Case 3.

Case vignette

The patient is a 27-year-old Moroccan man, who sees his general practitioner for headaches and related physical problems that do not allow him to function as he is accustomed to doing. He is concerned. The symptoms have persisted since a commotio cerebri caused when a car hit his bicycle about 6 months ago. Recently he has been seen by a neurologist, who could not find a specific cause other than the accident. The patient has a stable living situation with his wife and is working as supervisor of a cleaning crew, although he is trained as an electronic technician. Recently he was the target of discrimination by a colleague at work because of his Muslim background.

He is a man who was able to enjoy himself. He and his wife always got along quite well, but recently they have had some quarrels related to his current state. He has always been able to handle problems in his life well. He neither drinks nor smokes. He has never had periods of psychologic dys-functioning, except during the last month. He feels increasingly irritated and tense, and he cannot sleep. At the moment, nothing provides him much pleasure. Besides the hospital admission for the accident, the patient did not have any contacts with health care providers except for his general practitioner and the recent follow-up with the neurologist. This contact did not satisfy the patient; he felt he was not respected. The patient states that he is willing to do what the doctor suggests.

Treatment plan

Biologic. There is no evidence for a physical disease. There is need to monitor the patient's physical symptoms, but there is no need for further investigation.

Psychologic. There are no signs of previous vulnerability or poor coping. Because there is no history of somatization and poor coping, it is expected that a psychiatric diagnosis, including a clear explanation of the reason of his current state and his related concerns, will be an important first step in the treatment of the patient. It will provide a frame of reference for

Subject: Patient 1

Admission/referral date: 2006-04-03 00:00 Docter/nurse:

Department: Gasteroent

Reason for referral/admission: Diarrhoea and some Other complications

soore: 35

|hlistory jcurrent state

jprognoses |

Biological

Chronlcity

1 1 1 SnuArity nf <ymptv.m<

1 1 1

Complications and life-threat

Diagnostic dilemma

I I 1 Diagnostic challenge

1 . . 1 1

Psychological

Restrictions in coping

F&9HB9I Resistance to treatment

ill

Restrictions in

1—-J 1

Psychiatric dysfunction

1-1.1 Psychiatric symptoms

1 : 1 1

integration

1 . . 1 1

Social

Restrictions in integration

Residential instability

1-J ■ ■ 1

Social vulnerability

III

Social dysfunctioning

| - j ■ —| Restrictions of network

r 1

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ealth care

Intensity of treatment

1_l_l Organisation of care

i.i.i

Treatment experience

r • "T-----l Appropriateness of 1 "' I ' 1

1 ■ 1 ■ 1 referral l-l.l

Coordination

]Mo vulnerability nor need to art I---T ' 1 Mild vulnerability end need for monitoring or

'prevention nModerate vulnerability and need for treatment or Severe vulnerability and need for immediate inclusion in treatment plan action or intensive treatment

Fig. 9. Scoring of the case of patient 1.

treatment. In addition a psychologic intervention focusing on his hypochondriacal concerns, depressive cognitions, and his negative self-esteem intensified by the neglect he perceived during his interactions with the neurologist and his company's medical officer should reduce the patient's concerns and negative emotional state. Depending on the severity of depressive symptoms, antidepressants should be considered. His wife should be involved

Fig. 11. Scoring of the case of patient 3.

in the treatment, and the recent conflict resulting from the depression should be included as a focus of treatment.

Social. A plan for professional rehabilitation should be made.

Organization of care. This patient's case is not highly complex, as reflected in a total score of 17. Depending on his or her skills, the general practitioner should consider doing the assessment and the treatment as described. Alternately, the patient should be referred to a psychiatrist. Active coordination of care between the general practitioner and the company's medical officer (and the psychiatrist) is required. In this case, the coordination of care is primarily an exchange of diagnostic results and implementation of a subsequent integrated strategy.

Scoring of case examples

Figs. 9, 10, and 11 show the scoring of patients 1, 2, and 3, respectively.

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