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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 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 92 170/100 37.0 o 94% 18 GENERAL: HEENT: NECK: PULM: CV: ABD: EXT: NEURO: A&Ox3, anxious, diaphoretic Unremarkable Supple, no JVD Rales scattered (nonspecific) Systolic ejection murmur and s4 present Soft, NT/ND, + BS No C/C/E, palpable pulses all extremities MAE X 4, grossly intact LABS: See Appendix A Amylase/Lipase Level Comprehensive Metabolic Panel Arterial Blood Gas Hepatic Panel Basic Metabolic Panel X Lactate/Cortisol Level Cardiac Markers X Thyroid Panel Coagulation Profile X Toxicology Screen Complete Blood Count (CBC) Urinalysis CBC with differential X Urine HCG IMAGES: See Appendix B 16 Additional Labs: none Angiogram ECG X CT Scan, with contrast MRI CT Scan, without contrast X-Ray X Echocardiogram Ultrasound Additional Images: none CONSULTS: Cardiology – Dr. Jones: ECG is suggestive of left ventricular hypertrophy (LVH) but there are no other significant findings. Cardiology will recommend admitting the patient for a stress test, echocardiogram to evaluate aortic valve function and potentially cath. Cardiology consultant will encourage residents to establish diagnosis and management plan themselves, only providing minimal guidance as needed. CLINICAL PROGRESSION: History and physical, IV access, supplemental O 2 and monitor. Participants must rule out MI with appropriate laboratory studies and images, administer IV fluids, and determine whether or not to admit
Gilbert Program in Medical Simulation Simulation Casebook Harvard Medical School Draft of the 1 st edition (2011), updated 3/2/12 patient. Cardiology consult will recommend admitting patient for further evaluation including stress test with imaging, echo, possible cath. ***If nitroglycerin administered (with or without IV fluids), patient will complain of worsening symptoms and lightheadedness as blood pressure decreases: HR BP Temperature ( o C) O 2 Sats (RA) RR 92 120/90 37.0 o 93% 20 ***If IV fluids provided, pain and shortness of breath will moderately resolve: HR BP Temperature ( o C) O 2 Sats (RA) RR 90 150/100 37.0 o 96% 16 **Debriefing of first case can occur now (guide for debriefing found after PART II of case) VI. Case Narrative: Part II ***Patient name, past medical history, social and family history as above. CC: Chest pain, shortness of breath HPI: Use lay terminology as the voice of the patient Patient (above) was admitted to the inpatient unit and back to baseline vitals, more or less, but is having a second episode of chest pain and dyspnea, this time with lightheadedness. Atrial fibrillation with rapid ventricular response is displayed on the monitor. ROS: Initially as above PHYSICAL EXAM (Atrial Fibrillation): 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 156 80/40 37.0 o 95% 20 GENERAL: HEENT: NECK: PULM: CV: ABD: EXT: NEURO: A&Ox3, anxious, diaphoretic Unremarkable Slighty elevated JVD Rales scattered (nonspecific) Irregularly irregular tachycardia Soft, NT/ND, + BS No C/C/E, palpable pulses all extremities MAE X 4, grossly intact LABS: See Appendix A Amylase/Lipase Level Arterial Blood Gas Basic Metabolic Panel Comprehensive Metabolic Panel Hepatic Panel Lactate/Cortisol Level 17
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