SIMULATION CASEBOOK - MyCourses
SIMULATION CASEBOOK - MyCourses
SIMULATION CASEBOOK - MyCourses
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Gilbert Program in Medical Simulation<br />
Simulation Casebook<br />
Harvard Medical School Draft of the 1 st edition (2011), updated 3/2/12<br />
V. Case Narrative<br />
PATIENT: 64 year old<br />
CC: Chest pain, shortness of breath<br />
HPI: Use lay terminology as the voice of the patient<br />
Patient complains of worsening substernal chest pain over the past 3-4 hours that radiates to the left arm.<br />
Patient is short of breath, diaphoretic, and nauseated. Pain began while sitting and reading at home and is<br />
rated at a 10/10. Patient notes recent episodes of chest pain during exertion, resolving with rest.<br />
PMHx:<br />
Hypercholesterolemia<br />
Hypertension<br />
Lipitor<br />
Atenolol<br />
MEDICATIONS<br />
NKDA<br />
ALLERGIES<br />
PSHx: Denies<br />
SOCIAL Hx:<br />
EtOH:<br />
Tobacco:<br />
Illicits:<br />
Occupation:<br />
Additional:<br />
10 drinks/week<br />
½ pack/day<br />
Denies<br />
Waiter/waitress<br />
Lives with retired spouse<br />
FAMILY Hx:<br />
Father: Coronary Artery Disease, died of MI, age 84<br />
ROS:<br />
(+) Chest pain radiating to L arm, shortness of breath, nausea, diaphoresis, lightheadedness<br />
(-) Fever/chills, vomiting, diarrhea/constipation, blurred vision, numbness/motor weakness,<br />
abdominal pain, or urinary symptoms<br />
PHYSICAL EXAM: Those signs not demonstrable by the mannequin should be verbalized when<br />
students perform/verbalize the examination maneuver<br />
HR BP Temperature ( o C) O 2 Sats (RA) RR<br />
114 96/54 37.5 o 92% 18<br />
GENERAL: A&Ox3, anxious diaphoretic<br />
HEENT: PERRLA, EOMI, MMM<br />
NECK: Supple, no JVD<br />
PULM: Diffuse rales all fields<br />
CV: Tachycardic, regular rhythm, no murmur<br />
ABD: Soft, NT/ND, + BS, no mass/HSM<br />
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