SIMULATION CASEBOOK - MyCourses

Gilbert Program in Medical Simulation
Simulation Casebook
Harvard Medical School Draft of the 1 st edition (2011), updated 3/2/12
2. Cardiologist: reads ECG
V. Case Narrative
PATIENT: 63 year old
CC: Shortness of breath, cough
HPI: Use lay terminology as the voice of the patient
Patient presents with productive cough with increasing sputum and shortness of breath for 2-3 days,
cough x 4 months and shortness of breath x 2 days, which became markedly worse this morning. Cough
was initially non-productive, then gradually began bringing up non-bloody, yellowish phlegm. Patient
was hospitalized for ‘breathing issues” last year but has no history of intubations.
***If asked, patient has history of heavy tobacco use and “mild asthma.”
PMHx:
COPD: last steroids was 7 months ago
Arthritis
MEDICATIONS
Albuterol and Ipratropium inhalers
Advair
Naprosyn
PSHx: Denies
NKDA
ALLERGIES
SOCIAL Hx:
EtOH: Social
Tobacco: Quit
***If pressed further, quit 3 days ago after 2 pack/day x 34 years
Illicits: Denies
Occupation: Owner, public relations company
Marital status: Lives with wife, has 2 healthy kids (age 25, age 27)
FAMILY Hx: Unremarkable
ROS:
(+) Dyspnea, productive cough
(-) No nausea, vomiting, fever/chills, chest pain, headache, blurred vision, lightheadedness,
palpitations, numbness/motor weakness, abdominal pain, or urinary symptoms
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