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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 Aortic Stenosis: Angina Followed by Atrial Fibrillation I. Target Audience: Medical Students, Residents II. Learning and Assessment Objectives Participants are expected to understand the scientific and humanistic issues underlying the disease assessment and treatment plan, and to critically consider and deploy the therapeutic options described Participants should provide a concise presentation of the patient to each physician consultant who participates in the exercise. Debriefing sessions by on-site clinical faculty is essential to discuss critical thinking and knowledge pathways, and to provide a forum for individual and team reflection on learning and practice goals. While the case descriptions are written with medical terminology, it is important that the provider and patient (i.e. the simulator) engage in authentic dialogue with lay terminology to reflect an actual patient encounter. Critical Actions Checklist: DONE CRITICAL ACTION PART I Telemetry monitoring Patient history Physical examination Supplemental O 2 Immediate ECG and CXR Provide IV fluids Obtain appropriate laboratory studies: cardiac biomarkers Admit patient for stress test PART II Obtain additional history Repeat physical examination and immediate ECG Electrical or chemical cardioversion Initiate anticoagulant therapy Consider beginning longer acting rate/rhythm control agents after successful cardioversion III. Environment A. Simulation room set up: PART I in emergency department, PART II in either emergency department or on medical floor B. Manikin set up: 1. High fidelity patient simulator 2. No moulage needed 3. Lines needed C. Props: 1. Code blue cart 2. Lab values (see Appendix A) 3. Images (see Appendix B) D. Distracters: none 14
Gilbert Program in Medical Simulation Simulation Casebook Harvard Medical School Draft of the 1 st edition (2011), updated 3/2/12 IV. Actors A. Nurse: facilitate scenario B. Consultants (optional for higher level residents who can provide interpretation on their own) 1. Radiologist: reads chest x-ray 2. Cardiologist: reads ECG, recommends treatment plan V. Case Narrative: Part I PATIENT: 68 year old CC: Chest pain, shortness of breath HPI: Use lay terminology as the voice of the patient Patient presents with chest pain and shortness of breath that began while carrying pipes on a construction site. Patient feels like s/he is suffocating and describes chest pain as a dull pressure that has never been experienced before. Patient reports that many years ago, a primary care physician said s/he may need some “work” on her/his heart but patient “doesn’t know what that means.” Patient no longer sees the doctor. PMHx: Hypertension Rheumatic fever, as a child Prior asbestos exposure, shipyard Atenolol MEDICATIONS Aspirin ALLERGIES PSHx: Denies SOCIAL Hx: EtOH: Tobacco: Illicits: Occupation: Additional: Occasional Denies Denies Plumber Married, 2 children FAMILY Hx: Mother: Lung cancer, died age 74 Father: Diabetes, still alive ROS: (+) Diaphoresis, shortness of breath, chest pain (-) Nausea, vomiting, fever/chills, constipation/diarrhea, headache, blurred vision, lightheadedness, palpitations, numbness/motor weakness, abdominal pain, or urinary symptoms 15
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