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: 29 year old
CC: Headache
HPI: Use lay terminology as the voice of the patient
Patient presents with a throbbing left-sided headache that began gradually in the morning. This is similar
to past headaches the patient has had, though somewhat more severe. Pain is localized behind left eye and
started “out of the blue” this morning as patient woke up about 5 hours prior to arrival at emergency
department. Headache intensified when patient got up to use the bathroom this morning. Patient tried
Tylenol with no relief and is now starting to feel as though his/her vision may be getting a little blurry on
the left side where it really hurts.
Patient is scared that this is a stroke and doesn’t want to move his head because any movement makes the
pain worse. Patient reports some slight nausea and felt the need to vomit earlier but has not yet. Patient
feels a little dizzy and some possible numbness around the lips, mostly on the left side.
Patient has not eaten anything since last night where s/he reports partying a little more than usual, but
nothing really out of the ordinary, “had a glass of red wine and a few beers, came home and went to bed.”
Patent reports smoking a few cigarettes although typically not a smoker unless at a party and typically
doesn’t drink wine.
PMHx: Denies
MEDICATIONS
Ibuprofen, as needed
PSHx:
Appendectomy, age 16
Tonsilectomy, age 8
NKDA
ALLERGIES
SOCIAL Hx:
EtOH:
Tobacco:
Illicits:
Occupation:
Additional:
Socially
Occasionally
Denies
Architect
Dating, lives alone and has two healthy brothers
FAMILY Hx:
Father: “May have had a stroke when he was in his 60s”
Mother: Hypertension, migraines
ROS:
(+) Headache, photophobia, phonophobia, blurry vision on left side, nausea,
lightheadedness/dizziness
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