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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 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 122 80/60 42.0 o 98% 28 GENERAL: HEENT: CV: PULM: ABD: EXT: NEURO: Alert and oriented to person only (unsure of time or place), diaphoretic PERRL/EOMI, CN II-XII intact, flat neck veins Sinus tachycardia CTAB Soft, NT/ND, +BS No C/C/E, diminished peripheral pulses, no signs of compartment syndrome Does not follow commands, no focal deficit, flexion withdrawal to painful stimuli LABS: See Appendix A Amylase/Lipase Level Comprehensive Metabolic Panel Arterial Blood Gas Hepatic Panel X Basic Metabolic Panel X Lactate/Cortisol Level X Cardiac Markers Thyroid Panel Coagulation Profile Toxicology Screen X Complete Blood Count (CBC) Urinalysis X CBC with differential X Urine HCG IMAGES: See Appendix B 84 Additional Labs: Creatine kinase level Angiogram ECG X CT Scan, with contrast MRI CT Scan, without contrast X X-Ray X Echocardiogram Ultrasound Additional Images: none CONSULTS: PCP- Dr. Myers: Participants may page the Primary care provider to get background information on the patient, PMH, drugs, social hx, etc. No other clinical assistance will be provided. Nephrologist- Dr. Jefferson: Participants may page nephrology due to the elevated BUN/creatinine. Recommendation will include aggressive fluid resuscitation, cooling of the patient, and obtaining a creatine kinase (CK) level. Consult will also recommend treating the hyperkalemia and referring patient to ICU. (If the participants ask how to treat hyperkalemia, recommend sodium bicarbonate, calcium chloride or calcium gluconate, and insulin/glucose.) Intensivist- Dr. Adams: Recommend aggressive IV fluid resuscitation with normal saline and consider sodium bicarbonate therapy. Place a Foley catheter to measure urine output. Follow creatine kinase levels. Spray the patient with water and place a large fan next to him for evaporative cooling.
Gilbert Program in Medical Simulation Simulation Casebook Harvard Medical School Draft of the 1 st edition (2011), updated 3/2/12 CLINCAL PROGRESSION: Patient will be unable to provide an adequate history. Participants will get initial HPI and history from EMS that can be repeated at the onset per the confederate EMT/Paramedic or overhead voice. Participants should start IV/O 2 /monitor, begin assessing patient, provide IV fluids, and build a broad differential diagnosis. Students may request a consult from any one of the above consultants. Participants will be advised to continue fluids, cool the patient down, and admit to the ICU. If fluids and cooling measures are initiated the case will end with disposition to the ICU. If students fail to provide fluids within 10 minutes of start of case, patient vitals will worsen: HR BP Temperature ( o C) O 2 Sats (RA) RR 126 70/50 39.0 o 98% 28 VI. VII. Instructor Notes A. Tips to keep scenario flowing 1. If students start treating hyperkalemia but have not considered rhabdomyolysis, nurse can provide abnormal CK level to prompt participants for further management 2. Nurse can highlight abnormal BUN/creatinine to prompt participants to call nephrology B. Scenario programming 1. Optimal management path: O 2 /IV/monitor History and physical examination Aggressive fluid resuscitation Appropriate lab work-up: BMP, CBC, urinalysis, toxicology screen, lactate level, creatine kinase level, hepatic panel Appropriate imaging: ECG, CXR, head CT Treat hyperkalemia with insulin/glucose and calcium Initiate cooling measures 2. Potential complications/errors path(s): Failure to provide fluids 3. Program debugging: N/A Debriefing Plan A. Method of debriefing: Group with multimedia teaching materials B. Debriefing materials: See Appendix C C. Potential debriefing topics 1. Team dynamics i. Leadership ii. Collaboration iii. Communication iv. Professionalism 2. Didactic material i. Presentation a. Diversity of presenting complaints from muscle aches to acute renal failure and coma b. Broad differential diagnosis (can use a systems approach) c. Range of CK levels and timing of peak serum CK concentration 85
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