SIMULATION CENTER CASE TEMPLATE
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1 SIMULATION CENTER CASE TEMPLATE CASE CHIEF COMPLAINT: (does not include actual diagnosis) CASE NAME: PRESENTING SITUATION: (write a few sentences about the patients presenting problem) KEYWORD DESCRIPTIONS: (describe the patient s problem, parent disciplines, focus of the case, e.g. health risk appraisal, and other key words that characterize the case and the assessment challenge) DIFFERENTIAL DIAGNOSIS: (list competing diagnostic possibilities) ACTUAL DIAGNOSIS: DESIGNED FOR: (list what level of student this examination is designed for, i.e. 2nd year medical student; residents) ACTIVITIES & TIME REQUIRED: OBJECTIVES: (list learner objectives to be assessed or taught through use of this case, eg: 1) Development of data base, 2) Detection of findings 3) Time efficiency, 4) Interview and physical examination skills) STATION REQUIREMENTS: (list what is supplies and/or equipment is needed for this station, including patient and student paperwork) FOR MORE INFORMATION ABOUT THIS CASE: (supply name, address and phone number of the physician and case developer who designed the case) 1
2 SUMMARY OF CASE PROVIDE A SUMMARY OF THE CASE INCLUDING PRESENTING PROBLEM, LOCATION OF ENCOUNTER: STUDENT S TASK: STANDARDIZED PATIENT RECRUITMENT REQUIREMENTS DEMOGRAPHIC INFO (of SP to be recruited, not of patient): INCOMPATIBLE PATIENT CHARACTERISTICS: (i.e., someone with abdominal scars, hysterectomy scar, heart problems, etc.) 2
3 LEARNER INSTRUCTIONS PATIENT: AGE: CHIEF COMPLAINT: SETTING: TIME OF DAY: VITAL SIGNS: LEARNER TASK: Blood Pressure: Pulse: Respiration: Temperature: Pain: BMI: You have minutes to: 3
4 STANDARDIZED PATIENT TRAINING MATERIALS OVERVIEW Name: Objective Patient Description Gender: Age: Race: Height: Weight and/or BMI: Socioeconomic: Orientation: Marital Status: If single, do you live alone? If married, how many years? Children: Grandchildren: Address: Own or rent: Occupation: Duties at work: Spouse s occupation: Hobbies/Interests: Military History: Self-Presentation/Appearance: Patient affect Opening Statement After first open question: After additional open question: 4
5 Any information that must be provided, even if not elicited? When? Information to be volunteered in response to an open question, vs. Elicited information: After 5 min into the encounter At end of encounter Question- How has this affected you? Answer- Question- Have you noticed anything else? Answer Any questions that patient should ask of student? When? Any patient statements/actions that provide opportunities for empathic reflection by the student? Should patient respond differently to different types of students? Empathic: Unempathic: Other: Yes? No? Other encounter guidelines: HISTORY OF THE PRESENT ILLNESS SYMPTOMS Chief Complaint/Reason for Visit or Admission: Onset: Duration: Chronology: 5
6 Location: Radiation: Character: Severity: (scale of 1-10) Aggravating Factors: Alleviating Factors: Timing: Frequency: Course: (getting better or worse?) Context: (what was the setting/context of onset?) Associated Symptoms: Response to Symptoms: (what has the patient done about the symptoms other than seeking health care?) Consequences: (what do the symptoms interfere with?) Meaning of the illness: (patient s ideas, feelings, fears about the causes/implications) 6
7 ALLERGIES/ DRUG REACTIONS: CURRENT MEDICATIONS PATIENT S PAST MEDICAL HISTORY Overall Health: Childhood Illnesses: Adult Illnesses: Immunizations: (e.g. tetanus, DPT, MMR, etc. Give dates of latest immunizations.) Hospitalizations: Surgical Procedures: Injuries/Traumas Transfusions: Psychiatric History: Depression: Thoughts of suicide: Thoughts of harming others: Anxiety: PTSD: Mental health treatment: Mental health hospitalization: 7
8 Gynecological History: Start of Menses: Last period: Cycle: Duration of menses each month: Flow: Last gynecological exam: Last PAP and results: Any abnormal PAPs in past: Any pregnancies: Any miscarriages: If menopausal: Age it began: Taking estrogen: Disease Detection/Prevention: Yes/No When: Results: Visits physician regularly: Cholesterol checked: TB Test: Performs self breast/testicular exam: Visits dentist: Visits ophthalmologist: Lifestyle/Behavioral Risk Eating Habits: Exercise: Sleeping Habits: Stress: Tobacco: Alcohol: Illicit Drugs: 8
9 Sexual Habits: Current: Monogamous: Number of partners: Orientation: Form of birth control: Safe sex practices: Past: Monogamous: Number of partners: Orientation: Form of birth control: Safe sex practices: History of STDs: Tested for AIDS: FAMILY MEDICAL HISTORY Mother: Father: Sister(s): Brother(s): Grandparents(s): Spouse s Health: REVIEW OF SYSTEMS List any medical problems or findings the patient has that are important to the case. Only list those problems or findings that relate to the chief complaint at hand. GENERAL: SKIN: EYES: EARS: (e.g. rashes, lesions, easy bruising, pruritus, lumps, color change, hair or nail changes) (e.g. acuity, eyeglasses, contacts, photophobia, blurring, diplopia, spots, discharge, floaters, glaucoma, cataracts) (e.g. hearing changes, tinnitus, discharge, pain, vertigo) 9
10 NOSE, THROAT, SINUSES: MOUTH OR ORAL CAVITY: BREASTS: (e.g. congestion, hay fever, polyps, epistaxis, trauma) (e.g. painful teeth or gums, last dentist visit, sore tongue, sore throat, hoarseness) (e.g. lumps, pain, discharge, self exam, mammogram) RESPIRATORY: CARDIOVASCULAR: PERIPHERAL VASCULAR: (e.g. varicosities, thrombophlebitis, cramps, claudication, finger pallor or cyanosis) GASTROINTESTINAL: HEMATOPOIETIC: URINARY TRACT: MALE REPRODUCTIVE: FEMALE REPRODUCTIVE: (e.g. anemia, bruising, bleeding, transfusions, swollen glands) (e.g. difficulty in urination [dysuria], frequency, hesitancy, urgency, nocturia, polyuria, infections, incontinence, pyuria, hematuria, stones) (e.g. penile discharge, lesions, hernias, testicular pain, testicular mass, infertility, impotence, libido) (e.g. gravida/para: full term, pre-term, abortions, live children. Age of menarche, last menstrual period, frequency, duration, quantity of flow, dysmenorrhea. Age at menopause, symptoms of menopause. Contraception, last pelvic exam, last PAP test, dyspareunia) MUSCULOSKELETAL: ENDOCRINE: CENTRAL NERVOUS SYSTEM: (e.g. joint pain, stiffness, swelling, arthritis, gout, backache, muscle pain or stiffness, scoliosis, how much exercise) (e.g. thyroid trouble, goiter, heat or cold intolerance, excessive sweating, polyuria, polydypsia, polyphagia, hair/nail texture) (e.g. fainting, blackouts, headaches, seizures, local weakness, numbness, tremors, coordination, memory or attention deficits) PSYCHIATRIC: 10
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