1. Craig Smith Case Scenario
Presenting Complaint: / “I have a headache.”Gender and age: / 22 year old male
Case Name: / Craig Smith
Key Objectives:
All learners
- Demonstrate focused history PE
- State signs of clinical deterioration: Vital signs, pertinent physical exam findings (pale, dry mucus membranes, altered mental status & headache pain, photophobia, vomiting, guarded gait)
- Recognize and verbalize need for higher level of care
- Describe nursing interventions/
- Communicate critical information using SBAR during transfer; specifically unstable vital signs and altered mental status
- Complete comprehensive documentation appropriate to setting.
- Perform health history and focused assessment in a primary care setting: (PC learners)
- Refer to previous primary care SOAP note written on previous clinical exam (3 days prior to this visit)
- Complete a focused history and physical exam
- Report findings to facilitator
- Identify and manage a plan of care
- Complete appropriate documentation
- Transfer to the ED
- Provide complete handoff communication with ED learner using SBAR
- Perform health history and focused assessment in the ED setting: (ED learners)
- Complete a focused history and physical exam
- Institute appropriate basic care to patient: Monitoring, VS evaluation, oxygen therapy, history & physical assessment; IV, obtain blood, IVF); diagnostic evaluation (CT, CXR, CBC, Electrolytes, Blood Culture)
- Report findings to facilitator
- Identify and manage a plan of care
- Complete appropriate documentation
- Transfer to the ICU
- Provide complete handoff communication with ICU learner using SBAR
- Perform problem-focused health assessment in ICU setting: (ICU learners)
- Admit to ICU
- Complete a focused history and physical exam
- Institute appropriate basic care to patient Report findings to facilitator
- Identify and manage a plan of care
- Complete appropriate documentation
- Provide SBAR communication to facilitator
Brief summary: / Primary Care Setting:
Craig Smith has driven himself to his primary care provider office early this afternoon for headache. He has been on oral antibiotics for 3 days since being diagnosed with a bilateral otitis media in this office. Vital signs: 102.5° F oral; HR 110, radial; RR 22 unlabored; BP 90/60 sitting;
He took the antibiotic 3 times /day for 2 days; he vomited his last dose of antibiotic last evening and began having a severe headache. He took Tylenol for a fever: “I felt hot” and his antibiotic today, but vomited, He has been unable to take fluids today without vomiting. He is pale (facial make-up), and holding a basin with thick bilious emesis. His general affect is uncomfortable and distracted appearing, keeping his eyes closed or covering with his hand, as the lights are bothering him. The patient wants to lie down, but the headache is worse when he does so. He has trouble concentrating on learner’s questions, and does answer, but asks to have questions repeated intermittently. The questioning irritates him. He describes his headache as an 8/10 (0-10 scale 0 no pain, 10 worst pain. Pain is described as “throbbing” and more severe located to the back of the head. If asked about vision will have express blurred vision that he has just noticed and unable to identify examiners number of fingers.
After PC learner completes the physical examination, the standardized patient will hand him/her the “findings card”:
Denies facial tenderness to sinus palpation; Oral mucosa dry and pink, posterior pharynx red, without lesions or exudate; nares red and swollen without discharge; Bilateral tympanic membranes red and bulging; anterior cervical lymphadenopathy, nontender and shotty. No facial lesions.
Other findings that will be assessable on the standardized patient:
General: Acutely ill appearing, in pain, irritated, drowsy and eventually somnolent
Skin: Pale, underlying duskiness, dry, no rash
Lungs: Clear to auscultation bilaterally
Cardiac: S1,S2 regular, no murmurs
Abdomen: Soft, nontender, no hepatosplenomegaly
Extremities: non tender, no edema
After the history and PE, the PC learner will be instructed to step out of the examination room to discuss patient’s assessment findings and plan of care with the facilitator. The PC learner accompanies patient from the primary care office to the ED via wheelchair for further evaluation and management. SBAR handoff is given to the ED learner.
ED Setting:
In the ED, patient requires assistance transferring to the gurney; when standing he becomes weak and very lightheaded, to the point of falling, but not falling. He is nauseated, having intermittent dry heaves and is holding the emesis bucket closely…there is no new vomiting. Vital signs: Temp 102.8° F, HR 125, radial pulse weak, RR 26, unlabored; BP 88/56, supine; speech has slowed, requiring more prompting by the learner and now he is answering simply “yes” or “no” and is drifting off to sleep unless disturbed, somewhat restlessly moving side to side or onto his back, groaning with movements due to the pain; he cover’s his eyes when awake, but his arm relaxes away from his eyes when he sleeps. Additional information he may be asked: how is the headache…now he will just say “bad” and no longer able to quantify. Prompt student to attach cardiac and pulse oximeter monitors: the initial PO2 will be 87%, nasal cannula oxygen, once applied, improves O2 saturation to 96%. Blood work, IV and fluids will be instituted. Blood pressure will improve to 96/58 after fluid bolus. After physical assessment, the standardized patient will hand the participant the findings card (as above). While in the ED, patient’s level of consciousness deteriorates and becomes increasingly lethargic, with a worsening headache. CT scan demonstrates primary hydrocephalus. CXR is normal, CBCD: WBC 24.2, Hgb 17.1, HCT 48.2, K 5.2, Na 147, Mg 1.2; Blood culture pending; gram stain: few gram positive cocci. Patient is admitted to the ICU with appropriate handoff communication.
ICU Setting:
ICU Learners will admit and stabilize the patient. Vital signs: Temp 102.0° F., HR 105, thready, radial pulse. RR 22, shallow; BP 88/50; In the ICU, the patient will no longer be verbally responsive and will respond only to “noxious” stimulation: pinching of the arm or rubbing the breast bone firmly; his response will be to attempt to move away from the stimulation. ICU learner will admit, and support patient with monitoring and fluids. Again, the facilitator will assist to prompt documentation, SBAR communication and management for patient.
Medications: / Amoxicillin 875 mg p.o TID x 3 days
Tylenol 500 mg 2 tabs p.o q 4 hours for his headache W/O relief.
Allergies: / Morphine (gives him hives, and becomes short of breath)
Differential Diagnosis: / Acute Bilateral Otitis Media
Bacterial meningitis
Task(s) for examinee: / 1.PC learner – performs focused history and PE, recognize need for ED evaluation with facilitator, transfer and handoff to ED learner using SBAR
2.ED learner – performsfocused history and PE, emergency diagnostic work-up and management,recognize deterioration and the need for ICU admission and transfer and hand-off to ICU learner using SBAR.
3.ICU learner - performsfocused history and PE, institute appropriate stabilization and management and provide SBAR communication to facilitator
Exam Room/ED/ICU setting needs: / For all settings:
Audiovisual equipment for debrief playback, Stethoscope, Oto-and ophthalmoscope, Reflex hammer, tongue blade, gloves, hand sanitizer, Physical examination findings card
Moulage: Pale skin, dark circles under eyes;
Primary care (PC) setting:
Exam Table, Chart with Vital Signs, chief complaint, and previous visit SOAP note, Emesis basin with bilious emesis, Wheelchair;
Emergency Department (ED) setting:
Gurney, gown; thermometer labeled 102.8°F, Noninvasive blood pressure cuff: Labeled: Initial reading 88/56 (supine); after fluid bolus improved to 96/58, Pulse oximeter, labeled at 87% initially, improves to 96% after O2 applied, 02 Wall mount; O2 nasal cannula, Cardiac monitor: Heart Rate (HR) 125 Sinus tachycardia (ST), Intravenous (IV) start kit, angiocath, IV tubing and bag, Laboratory and Radiology findings card: CBC, electrolytes, Blood cultures; CXR, Head CT results.
Intensive Care Unit (ICU) setting:
Cardiopulmonary monitor labeled HR 105, ST; BP 88/50, Pulse oximeter, Thermometer: 102°.
Post-Encounter Station Needs: / Tables, chairs, dry erase markers for debrief, audiovisual debrief playback equipment
Data collection tools: / PC and ED SOAP Notes, ICU note
2. SP Training Notes
Case Name
/ Craig SmithPresenting Situation / Headache, vomiting x 2 today, & nausea; fever.
It is early afternoon.
Psychosocial Profile / 22 yo male. Lives in an apartment with a similar aged male friend who is a friend; He graduated from college last year and is working in a bank as an Internet technical support person.
He has a good group of friends, but no special girlfriend at the moment.
He is from local city, and his family lives in locally.
He drinks alcohol socially, 1-2 beers several evenings a week.
He exercises at a local gym about 1 hour or so per day.
He likes to visit with friends, see movies, go to plays, and out to dinner.
He is generally an upbeat and easygoing young man.
He is dressed casually, in a t-shirt and basketball shorts, appropriately for the season.
Opening Statement / “I have had a headache for since last night”.
History of Present Illness / You have driven to your primary care provider’s office early this afternoon for a headache. You have been taking oral antibiotics for 3 days since being diagnosed with ear infections in this office. You took the antibiotic 3 times/day for 2 days; last night you vomited the evening dose of the antibiotic. During the night last night, you began having a severe headache. You took Tylenol for a fever: “I felt hot”, and his antibiotic today, but vomited. You have been unable to take fluids without vomiting. You are holding a basin with thick green vomit and are very uncomfortable, with frequent bouts of dry heaving. You are having difficulty paying attention to the learner’s questions and following commands without asking for the questions to be repeated, but you do answer each question appropriately. You feel very irritated by the examiner’s questions and are a bit short-tempered. The light is bothering you, to the point that you keep your eyes closed, or covered with your hand; you want to lie down, but it makes you head pain worse. You describe your headache pain as “throbbing” and worse at the back of your head; if asked to describe the headache pain on a 0-10 scale (0 no pain, 10 the worst possible pain) you answer saying 8/10. If asked about vision state that it is blurred, and you have just noticed that when asked; you will not be able to identify examiners number of fingers;
Additional information if asked by learner:
- Other medications: Acetaminophen 500 mg 2 tablets last kept down 6 PM last evening;
- Fever: has felt very hot, but does not have a thermometer;
- Sleep: A restless night with difficulty sleeping;
- Fluid intake: None today d/t vomiting;
- Urine output: urinated this morning;
- GI symptoms: Nausea, vomiting which is green and thick; denies diarrhea; has some generalized abdominal pain from vomiting;
- Immunizations: Updated Flu, meningitis shot,and tetanus booster
Oral mucosa dry and pink, posterior pharynx red, without lesions or exudate; nares red and swollen without discharge; Bilateral tympanic membranes red and bulging; anterior cervical lymphadenopathy, nontender and shotty. No facial lesions.
After the history and physical exam, the learner will step out of the examination room to discuss patient’sfindings and plan of care with the facilitator. Your learner will return and explain that you will need to be evaluated in the Emergency department, that there is some concern that the ear infection has worsened, which is causing your headache; you agree to this plan. You are moved to a wheelchair and accompanied by the learner from the primary care office to the ED; while the learners talk about you continue to be uncomfortable, a bit restless, covering your eyes, and having dry heaving into the bucket of vomit, Always remain in character.
In the ED: You require assistance to transfer from the wheelchair to the gurney. When you begin to stand you feel very weak and lightheaded and almost to the point of falling, but not falling. You are continuing to have intermittent dry heaves, holding the vomit bucket closely…there is no new vomiting. You a feeling very sleepy and doze off now and then once you have been laid down; you awaken to questions, but your speech has slowed, requiring more prompting by the learner, and now answering simply “yes” or “no”. Drifting off to sleep unless disturbed, somewhat restlessly moving side to side or onto your back, groaning with movements due to the pain; you cover your eyes when awake, but your arm relaxes away from your eyes when asleep. Additional information you may be asked: how is the headache…now you will just say “bad” and no longer able to quantify. Learners will place an IV,put you on monitoring equipment and give you oxygen in your nose. After these procedures are completed you become mostly asleep, and if arouses, the headache pain is much more severe. You are told you are being admitted to the ICU, and at about this time, you become completely asleep and no longer responding to voice or commands.
In the ICU you are basically comatose, you do not answer to any questions and in fact your only response is to “noxious” stimulation: pinching of the arm or rubbing the breast bone firmly; your response will be to move away from the “irritation”. Remain in character, asleep on the gurney until the scenario is completed.
Medications / MVI one capsule daily (did not take today) & Tylenol 500 mg two tabs by mouth every 4 hours; last dose 6 PM last evening.
Allergies / Morphine: causes you to have a rash
Past Medical History / Appendectomy at age 15, no other surgeries or significant medical history.
Social History / College graduate; full-time employment in Internet Technology; family lives locally; he lives with one male roommate who is a good friend; social, no special partner; drinks 1-2 beers weekly; denies tobacco, recreational drug use; exercises regularly.
Family Medical History / Parents are healthy. No siblings.
3. PRESENTING SITUATION (chart note)
Patient Name:Craig Smith
Setting:Continuity of Care: Primary Care Clinic, then ED, then ICU
Primary Care Clinic:
Vitals:Temp102.5° F., oral;
HR110 radial pulse
RR 22, unlabored
BP90/60 sitting
ED:
Vitals: Temp 102.8 °F.
HR 125, radial pulse weak
RR 26 unlabored
BP 88/56 supine
ICU:
Vitals: Temp 102.0° F
HR 105, thready, radial pulse
RR 22, shallow
BP 88/50
Complaint:Patient complains of headache, nausea, vomiting and fever.
You have 30 minutes to complete a focused history and physical exam, meet with your facilitator, and to discuss your findings and plan with your patient.
After you are finished, please return to the front of the lab; where you have 30 minutes to complete a written SOAP note and debrief.
4. Findings Cards
Patient Name: Craig Smith
Finding card:
Oral mucosa dry and pink, posterior pharynx red, without lesions or exudate; nares red and swollen without discharge; Bilateral tympanic membranes red and bulging; anterior cervical lymphadenopathy, nontender and shotty. No facial lesions.
Findings Card for laboratory and imaging for ED and ICU setting:
Complete Blood Count: White Blood Cells: 24.2, Hemoglobin 17.1, Hematocrit 48.2%, Diff pending
Electrolytes: Sodium: 147, Potassium 5.2, Magnesium 1.2
Blood Cultures: pending, Gram stain: gram positive cocci (few)
Chest x-ray: Negative
Head CT: Primary Hydrocephalus
5. Initial Visit SOAP Note
Name: Craig Smith Allergies: Codeine Date: (3 days prior to scenario)
T: 101.8 P: 100 RR: 22 BP: 110/70 Wt:(use SP weight) Ht: (use SP height) Age: 22
CC: “My ears hurt.”
S: 2 day history bilateral ear pain, worse today
Fever x 2 days – no thermometer, feels hot & sweaty
Some nasal congestion (mild) & sore throat for 3-4 days
No difficulty swallowing, no nausea or vomiting, + appetite, drinking fluids
Poor sleep last night due to pain
No medications routinely taken
No medications taken for present illness
O: Alert & oriented, color pink, skin warm/dry, S1S2, no murmur; BBS CTA, respiratory effort easy, non-labored; Head nontraumatic, normocephalic, O/P moist, pink, no lesions; no facial/sinus tenderness to palpation; Bilateral TM’s full and bulging; negative TMJ click or pain, positive bilateral anterior cervical lymphadenopathy; Nares: turbinates mildly red with scant clear thick discharge;
A: Bilateral otitis media
P:Diagnostics: None
Therapeutics: Amoxicillin 875 mg po TID x 10 days
Acetaminophen 500 mg tabs 2 po q 4 hours prn fever/pain
Patient Education: Increase fluids, rest, comfort care
Follow-up: RTC in 3 days if fever continues,
Sooner for increased pain or headache, vomiting, worsening
condition or concerns
Signature: Susan Bonnell, NP
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