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: 62 year-old<br />
CC: Mid-epigastric discomfort<br />
HPI: Use lay terminology as the voice of the patient<br />
Patient presents with 2 hours of mid-epigastric pain that is not relieved by antacids. Pain began while<br />
patient was out walking. Patient has had similar “ulcer” symptoms while working in the yard or walking<br />
up stairs during the past few weeks. This time, the pain is not going away and is non-radiating.<br />
PMHx:<br />
GERD<br />
IDDM<br />
Insulin<br />
Ranitidine<br />
MEDICATIONS<br />
Penicillin<br />
ALLERGIES<br />
PSHx: Denies<br />
SOCIAL Hx:<br />
EtOH:<br />
Tobacco:<br />
Illicits:<br />
Occupation:<br />
Occasional<br />
1 pack/day, x30 years<br />
Denies<br />
Accountant<br />
FAMILY Hx:<br />
Brother: MI at age 55<br />
ROS:<br />
(+) Substernal chest pain, diaphoresis, nausea, dyspnea<br />
(-) No fever, chills, palpitations, vomiting, headache, blurred vision, numbness/motor weakness,<br />
melena, blood in stools 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 Sat (RA) RR<br />
40 90/50 37.0 o 97% 24<br />
GENERAL:<br />
HEENT:<br />
NECK:<br />
PULM:<br />
CV:<br />
ABD:<br />
A&OX3, uncomfortable<br />
WNL<br />
Mild JVD<br />
CTAB<br />
Bradycardic, regular rhythm, no murmur/rub/gallop<br />
Soft, NT/ND, +BS<br />
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