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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 100
Gilbert Program in Medical Simulation Simulation Casebook Harvard Medical School Draft of the 1 st edition (2011), updated 3/2/12 ROS: (+) Diarrhea, slight nausea, rectal bleeding, abdominal pain, orthostasis (-) No melena, vomiting, fever/chills, abdominal distention, headache, dysuria, hematuria, weight loss, rashes, joint pains, headaches, vision changes, shortness of breath, cough, or chest pain. PHYSICAL EXAM: Those signs not demonstrable by the mannequin should be verbalized when students perform/verbalize the examination maneuver HR BP Temperature ( o C) O 2 Sats (RA) RR 108 122/82 37.4 o 100% 16 GENERAL: HEENT: PULM: CV: ABD: EXT: RECTAL: SKIN: NEURO: Alert. Appears anxious, pale, and diaphoretic, but not in any acute distress Anicteric sclera. Pale conjunctiva. Supple neck. Dry mucosal membranes. No cervical or supraclavicular lymphadenopathy CTAB, no dullness to percussion Regular tachycardia. No murmurs Soft, non-distended, very mild tenderness on the left lower quadrants on deep palpation. No inguinal or femoral hernias. No masses. No HSM No peripheral edema No external hemorrhoids, no internal masses, non-tender, no stool in the rectal vault, but gross blood on glove No rashes and no jaundice. Grossly normal. LABS: See Appendix A Amylase/Lipase Level X Comprehensive Metabolic Panel Arterial Blood Gas Lactate/Cortisol Level X Basic Metabolic Panel X Hepatic Panel X Cardiac Markers Thyroid Panel Coagulation Profile X Toxicology Screen Complete Blood Count (CBC) Urinalysis X CBC with differential X Urine HCG IMAGES: See Appendix B Additional Labs: none Angiogram CT Scan, with contrast CT Scan, without contrast Echocardiogram ECG MRI X-Ray Ultrasound 101 Additional Images: Endoscopy CONSULTS: Gastroenterologist – Dr. Cole: Consult may advise participants to provide IV fluids if they fail to do so.
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