1. Craig Smith Case Scenario
“I have a headache.”
22 year old male
Craig Smith
1. Perform health history and focused assessment in a
primary care setting: (PC learners)
All learners
a. Refer to previous primary care SOAP note written
1. Demonstrate
on previous clinical exam (3 days prior to this visit)
focused history &
b. Complete a focused history and physical exam
PE
c. Report findings to facilitator
2. State signs of
d. Identify and manage a plan of care
clinical
e. Complete appropriate documentation
deterioration: Vital
f. Transfer to the ED
signs, pertinent
g. Provide complete handoff communication with ED
physical exam
learner using SBAR
findings (pale, dry
2. Perform health history and focused assessment in the ED
mucus membranes,
setting: (ED learners)
altered mental
a. Complete a focused history and physical exam
status & headache
b. Institute appropriate basic care to patient:
pain, photophobia,
Monitoring, VS evaluation, oxygen therapy, history
vomiting, guarded
& physical assessment; IV, obtain blood, IVF);
gait)
diagnostic evaluation (CT, CXR, CBC,
3. Recognize and
Electrolytes, Blood Culture)
verbalize need for
c. Report findings to facilitator
higher level of care
d. Identify and manage a plan of care
4. Describe nursing
e. Complete appropriate documentation
interventions/
f. Transfer to the ICU
management of
g. Provide complete handoff communication with
unstable patient:
ICU learner using SBAR
specifically need
3. Perform problem-focused health assessment in ICU
for transfer to
setting: (ICU learners)
higher level of care
a. Admit to ICU
and interventions
b. Complete a focused history and physical exam
(hydration,
c. Institute appropriate basic care to patient Report
hemodynamic
findings to facilitator
monitoring, labs,
d. Identify and manage a plan of care
imaging)
e. Complete appropriate documentation
5. Communicate
f. Provide SBAR communication to facilitator
critical information
using SBAR
during transfer;
specifically
unstable vital signs
and altered mental
status
6. Complete
comprehensive
Presenting Complaint:
Gender and age:
Case Name:
Key Objectives:
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documentation
appropriate to
setting.
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 (010 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.
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Medications:
Allergies:
Differential Diagnosis:
Task(s) for examinee:
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.
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.
Morphine (gives him hives, and becomes short of breath)
Acute Bilateral Otitis Media
Bacterial meningitis
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 – performs focused 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.
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Exam Room/ED/ICU
setting needs:
Post-Encounter Station
Needs:
Data collection tools:
3. ICU learner - performs focused history and PE, institute
appropriate stabilization and management and provide
SBAR communication to facilitator
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°.
Tables, chairs, dry erase markers for debrief, audiovisual debrief
playback equipment
PC and ED SOAP Notes, ICU note
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Case Name
Presenting
Situation
Psychosocial
Profile
Opening Statement
History of Present
Illness
2. SP Training Notes
Craig Smith
Headache, vomiting x 2 today, & nausea; fever.
It is early afternoon.
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.
“I have had a headache for since last night”.
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
After examiner completes the physical examination, then you will hand
him/her the physical exam findings card:
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Medications
Allergies
Past Medical
History
Social History
Family Medical
History
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’s findings 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.
MVI one capsule daily (did not take today) & Tylenol 500 mg two tabs by
mouth every 4 hours; last dose 6 PM last evening.
Morphine: causes you to have a rash
Appendectomy at age 15, no other surgeries or significant medical 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.
Parents are healthy. No siblings.
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3. PRESENTING SITUATION (chart note)
Patient Name: Craig Smith
Setting:
Continuity of Care: Primary Care Clinic, then ED, then ICU
Primary Care Clinic:
Vitals:
Temp
HR
RR
BP
102.5° F., oral;
110 radial pulse
22, unlabored
90/60 sitting
Temp
HR
RR
BP
102.8 °F.
125, radial pulse weak
26 unlabored
88/56 supine
Vitals:
Temp
HR
RR
BP
102.0° F
105, thready, radial pulse
22, shallow
88/50
Complaint:
Patient complains of headache, nausea, vomiting and fever.
ED:
Vitals:
ICU:
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.
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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
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5. Initial Visit SOAP Note
Name: Craig Smith
Allergies: Codeine
T: 101.8 P: 100 RR: 22 BP: 110/70
Wt: (use SP weight)
Date:
(3 days prior to scenario)
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:
Therapeutics:
None
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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