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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 V. Case Narrative PATIENT: 62 year-old CC: Mid-epigastric discomfort HPI: Use lay terminology as the voice of the patient Patient presents with 2 hours of mid-epigastric pain that is not relieved by antacids. Pain began while patient was out walking. Patient has had similar “ulcer” symptoms while working in the yard or walking up stairs during the past few weeks. This time, the pain is not going away and is non-radiating. PMHx: GERD IDDM Insulin Ranitidine MEDICATIONS Penicillin ALLERGIES PSHx: Denies SOCIAL Hx: EtOH: Tobacco: Illicits: Occupation: Occasional 1 pack/day, x30 years Denies Accountant FAMILY Hx: Brother: MI at age 55 ROS: (+) Substernal chest pain, diaphoresis, nausea, dyspnea (-) No fever, chills, palpitations, vomiting, headache, blurred vision, numbness/motor weakness, melena, blood in stools or urinary symptoms 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 Sat (RA) RR 40 90/50 37.0 o 97% 24 GENERAL: HEENT: NECK: PULM: CV: ABD: A&OX3, uncomfortable WNL Mild JVD CTAB Bradycardic, regular rhythm, no murmur/rub/gallop Soft, NT/ND, +BS 34
Gilbert Program in Medical Simulation Simulation Casebook Harvard Medical School Draft of the 1 st edition (2011), updated 3/2/12 EXT: NEURO: No C/C/E, palpable pulses all extremities WNL, MAE X 4, grossly intact, anxious during exam LABS: See Appendix A Amylase/Lipase Level Arterial Blood Gas Basic Metabolic Panel X Lactate/Cortisol Level Cardiac Markers X Thyroid Panel Coagulation Profile X Toxicology Screen Complete Blood Count (CBC) X Urinalysis CBC with differential Urine HCG Comprehensive Metabolic Panel Hepatic Panel IMAGES: See Appendix B 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 will be read as STEMI in inferior leads. Cardiology will recommend preparing the patient for cardiac catheterization: Aspirin, Plavix, heparin, and “if it’s safe in light of the patients’ vital signs,” nitroglycerin. Indicate that the patient needs to be stabilized prior to catheterization. Ask the students to notify the patient of the catheterization procedure. Cardiology can also suggest giving atropine and/or transcutaneous pacing for bradycardia. If vitals have not been stabilized, tell participants to call back after blood pressure and other vitals improve. If participants ask about increasing the pressure safely, recommend IV fluids. Cardiology consultant will encourage participants to establish diagnosis and management plan themselves, providing guidance with medication recommendations. Radiology – Dr. Smith: CXR will be read as normal x-ray. (advanced participants should interpret) CLINICAL PROGRESSION: History and physical, IV/O 2 /monitor with immediate aspirin, stat portable CXR and ECG indicative of inferior MI. Students should start aggressive reperfusion with 2 liters of Normal Saline after physical exam and ECG reading as well as administer pharmacologic therapy including pressor agent if hypotension persists, and anticoagulants. Students should consider administering atropine and must discuss further treatment with interventional cardiology and admit patient to catheterization lab. 35
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