SIMULATION CASEBOOK - MyCourses

Gilbert Program in Medical Simulation
Simulation Casebook
Harvard Medical School Draft of the 1 st edition (2011), updated 3/2/12
V. Case Narrative
PATIENT: 45 year-old
CC: Diarrhea and rectal bleeding
HPI: Use lay terminology as the voice of the patient
Ms./Mr. Jones is a 45-year-old African American (wo)man who presents with diarrhea and rectal
bleeding. Patient was in her usual state of good health until one day ago when patient developed some
crampy lower abdominal pain and loose stools. The pain is associated with bowel movements, and
improves after passing stool. The pain does not radiate, and is 4-5/10 in intensity.
Patient had 8-9 bowel movements yesterday, and then overnight had several more loose bowel
movements that were mainly red blood with a small amount of liquid stool. Patient stated that the blood
seemed to fill the toilet bowl, and that it caused a lot anxiety as patient has never had that much rectal
bleeding before. Patient has hemorrhoids and has had intermittent bleeding in the past, but never as much
as in the past 24 hours. Patient has not had any fevers, but did have some nausea without any vomiting.
Patient also states that his/her bowel movements have decreased in frequency over the past several hours,
with last bowel movement being five hours prior.
PMHx:
Hypertension
Depression
MEDICATIONS
Multivitamin daily
Aspirin 81 mg daily
Hydrochlorothiazde 12.5 mg daily
Penicillin
ALLERGIES
SOCIAL Hx:
EtOH:
Tobacco:
Illicits:
Occupation:
Additional:
3-4 drinks/week
Denies
Denies
Lawyer
Married, lives with spouse and two children, does not take any herbal medications or
other over-the-counter medications.
FAMILY Hx:
Father: MI, age 67
Mother: Colon cancer diagnosis, age 49
Sister: Healthy
Brother: Prostate cancer
No family history of inflammatory bowel disease
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