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: 19 year old
CC: Abdominal pain, vomiting
HPI: Use lay terminology as the voice of the patient
Patient presents complaining of nausea, vomiting, and abdominal pain which started last night. Patient
reports feeling weak, confused, and thirsty for the last 3 days. Patient is actively throwing up during the
H&P. When asked about abdominal pain, patient reports pain is diffuse, does not localize and does not
migrate. Patient reports onset of subjective fever this morning after waking up (did not take temperature).
Patient denies any recent illness, change in diet, foreign travel, chemical exposure or sick contacts.
If asked, patient reports urinating more frequently in the last 2-3 days. Denies dysuria.
PMHx:
Denies
Denies
MEDICATIONS
Penicillin
ALLERGIES
SOCIAL Hx:
ETOH:
Tobacco:
Illicits:
Occupation:
Additional:
Occasional
Denies
Denies
Auto mechanic
Lives alone
FAMILY Hx:
Adopted, does not know family history.
ROS:
(+) Fever, nausea, vomiting, abdominal pain, increased urinary frequency, shortness of breath,
polydipsia over last three days until last night
(-) No chest pain, headache, neck pain, cough, dysuria, diarrhea/constipation, blood in stool,
hematemesis
PHYSICAL EXAM: Those signs not demonstrable by the mannequin should be verbalized when
students perform/verbalize the examination maneuver
HR BP Temperature O 2 Sats (RA) RR
140 80/60 37.5 96% 30
GENERAL:
HEENT:
CV:
PULM:
ABD:
Alert to person, place only (A&Ox2).
Dry mucous membranes, neck supple, no meningismus
Tachycardic, no murmurs
Rapid deep breaths, clear to auscultation
Diffuse tenderness, no localizing pain, soft, non-distended, + BS.
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