SIMULATION CASEBOOK - MyCourses

Gilbert Program in Medical Simulation
Simulation Casebook
Harvard Medical School Draft of the 1 st edition (2011), updated 3/2/12
VI.
Case Narrative: Part II
***Patient name, past medical history, social and family history as above.
CC: Worsening shortness of breath, lightheadedness
HPI: Use lay terminology as the voice of the patient
Patient is now on the inpatient ward with a diagnosis of chest pain rule-out MI and COPD (or perhaps a
diagnosis of pulmonary embolism if the participants got that far). Patient is complaining of
lightheadedness and has a declining level of consciousness.
As patient is complaining (3-5 minutes), patient has a PEA arrest.
ROS: As above, apart from increasing lightheadedness.
PHYSICAL EXAM: Physical findings as above
HR BP Temperature ( o C) O 2 Sats (RA) RR
130 80/50 37.5 o 76% 28
***Labs and images available are listed above.
CONSULTS:
Cardiology-Suggest to go through the “H’s and T’s” for cause of PEA.
Advanced participants may consider cardiology consultation for stat echocardiogram or cardiothoracic
surgery for embolectomy.
CLINICAL PROGRESSION:
Participants must re-examine patient, obtain any additional history, and re-initiate O 2 therapy. As patient
falls into PEA arrest, participants must perform immediate CPR. If started, after one round of chest
compressions, the patient will recover a blood pressure, previous vitals will return, and anti-coagulation
and/or TPA should be ordered, and case will end.
***If supplemental O 2 is provided, patient improves slightly but O 2 saturation stays below 90%
EKG and CXR if ordered are unchanged. Cardiac enzymes are negative. Oxygen helps some but not
enough to get the O2 sat into the 90s.
VII.
Instructor Notes
A. Tips to keep scenario flowing
1. Cardiology or pulmonary consult can be used to prompt participants to admit patient
in Part I of case if they appear unsure about further management.
B. Scenario programming
1. Optimal management path:
O 2 /IV/monitor
History and physical examination
45