SIMULATION CASEBOOK - MyCourses

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: 56 year old
CC: Vomiting, chills, acute abdominal pain
HPI: Use lay terminology as the voice of the patient
Patient presents with uncontrollable nausea and vomiting with acute abdominal pain. Patient claims to
not have been able to keep food down for two days. “Maybe something I ate?”
The patient denies diarrhea.
PMHx:
Denies diabetes, blood pressure, heart issues
MEDICATIONS
Denies
PSHx: Denies
SOCIAL Hx:
Penicillin
ALLERGIES
EtOH:
Tobacco:
Illicits:
Occupation:
Additional:
Needs to be asked directly and pressed to admit alcohol use. Eventually admits history of
alcohol abuse or nurse will relate the fact from past hospital admission records.
“I haven’t had a drop in over two days.” Eventually admits a binge three days ago at a
friend’s house. “He bought some of this fancy black rum thing.”
Occasional
Vigorously denies, latches on to that part of the question
Temp secretary, registered with a local agency but is currently “between assignments.”
Lives alone
FAMILY Hx: Unremarkable
ROS:
(+) Nausea, vomiting, abdominal pain, dyspnea, dizziness
(-) Muscle pain, diarrhea, syncope, seizure, or melena
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
112 90/50 36.0 o 99% 24
GENERAL:
HEENT:
NECK:
PULM:
In mild distress, but nontoxic appearing, smelling of ketones (nail polish remover on
cotton balls, placed by the head of the mannequin)
Dry mucous membranes
Supple, no JVD
Clear to auscultation bilaterally
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