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: 20 year old
CC: Altered mental status
HPI: Use lay terminology as the voice of the patient
Patient brought in by ambulance after friends called 911 when patient was “acting funny.” Patient
appears intoxicated. Patient is a limited historian due to altered mental status. Patient refuses to answer
the questions pertaining to the event and his/her past medical history, continually responding with
inappropriate or unrelated statements and a desire to “get outta here.”
***After normalization with glucose, patient calms down and reports that s/he had been out with friends
all day and taken daily dose of insulin but had forgotten to eat.
PMHx:
DM Type I
Insulin
MEDICATIONS
NKDA
ALLERGIES
PSHx: Denies
SOCIAL Hx:
EtOH:
Tobacco:
Illicits:
Occupation:
Additional:
Occasional
Rarely
Denies
College student
Lives in a dorm at school
FAMILY Hx: Unremarkable
ROS (initially):
(+) Altered mental status. Otherwise, impossible to retrieve.
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
114 128/70 37.0 o 98% 12
GENERAL:
HEENT:
NECK:
PULM:
CV:
ABD:
EXT:
Atraumatic, agitated, confused
Cheeks flushed, TM clear bilaterally, PERRL, EOMI, nares clear, OP erythematous
Supple, JVP not elevated
CTAB
Tachycardia, regular rhythm
Soft, NT/ND, no masses, +BS
No C/C/E, palpable pulses all extremities
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