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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 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 158
Gilbert Program in Medical Simulation Simulation Casebook Harvard Medical School Draft of the 1 st edition (2011), updated 3/2/12 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 92 120/80 37.0 o 88% 24 GENERAL: HEENT: NECK: PULM: CV: ABD: SKIN: EXT: Appears tired, able to speak in short sentences Ruddy faced, TM clear bilaterally, PERRL, EOMI, nares clear, OP erythematous Supple, JVP not elevated Somewhat barrel chested; diffuse wheezing bilaterally with poor air movement S1, S2, tachycardic, regular, no M/R/G Soft, benign, no masses No rashes, warm to touch, cap refill
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