Prototype Case Presentation

Source: www.doctorshangout.com

Prototype Case Presentation

              

Patient profile, presenting complaint

I would like to
<introduce || present the case of>
<Mrs X>,
a
<60 year old>
<steelworker>
from
<Dublin>
who was admitted
<through casualty || by her GP>
following a
<12 hour>
history of
<dyspnea and crushing chest pain>.

History of presenting complaint

In regards to the past medical history, she last felt well
<6 months>
ago.

Then she began to notice
<a full description of old attacks of the complaint>
which was
<getting better || worse || constant>
over time.

Then,
<today>
she
<pain>
came on
<suddenly>
while she was
<climbing a steep hill>.

She described the
<pain>
as a
<crushing pain>
<localized || diffuse> in the
<center of her chest>
of severity
<9/10>
which radiated
<down her left arm>.

The pain was
<constant || intermittent>
lasting for
<30 minutes>,
and was made worse by
<attempting to walk>,
but relieved by
<using her GTN spray>.

She came into
<hospital || her GP> at
<9:00 am on Mar 11th>
where she was given
<morphine>
which
<relieved the pain>,
and administered a
<EKG>
test which showed
<findings of an MI>.
Patient was
<admitted to the cardiac ward || discharged>
and her current symptoms are
<improving || stable || yet to stabilize>.

If relevant to disease:
She has had
<2>
similar attacks in the past
<4 years>
with
<increasing || decreasing || similar>
severity and frequency.
<all || but none>
of which required admission to
<hospital || ICU>.

Past medical history

<Mrs X> has
<type II diabetes>,
first diagnosed in
<1997>
which is controlled well
<glucophage, and diet>.
She has
<No || a>
past history of
<MJ THREADS, and details of any>.
and reports
<some depression || no depression>.

Past surgical history

A
<appendectomy>
was performed in
<1974>
with
<no complications || complications of...>
and
<no reaction || a reaction of...>
to the anesthetic.

Gynecological history

Menarache was at the age of
<13>.

If menopause:
and menopause was at age
<65>.
If no menopause:
Periods are
<regular || irregular>
with
<normal || heavy || intermittent>
bleeding.
Cyles are
<28 days>,
periods last
<3 days>,
and first day of her last period was
<March 3rd>.

She has
<3>
children, delivered with
<no complications || complications of...>.

She had
<zero>
miscarriages, and
<no chance of || some chance of || is>
currently pregnant.

Family history

<No one || her sister...>
has experienced symptoms similar to her current complaint.

If any family members with similar symptoms:
<Details of dz in each...>

Her father passed away at
<65>
from
<a stroke>.

Her mother passed away at
<75>
from
<breast cancer>.

Her brother has
<severe angina>,
first diagnosed at age
<40>.

Her children are
<in good health || dz's in children...>.

Extended family has
<nothing of note>.

Sexual history

If sexually active and relevant:
Last intercourse was
<March 6th>
with
<14>
total number of contacts, in
<heterosexual || homosexual || bisexual>
relationships, and
<no || number of...>
contacts with prostitutes.

Social history

<Mrs. X>
was born in
<Cork>
and currently resides in
<Dublin>.

Her present occupation for the last
<15 years>
is
<steelworker>
where she
<pours hot steel>
and there is
<no || number of...>
coworkers there with similar symptoms.

Previous occupations included
<butcher>
for
<3 years>
with
<no || number of...>
coworkers with similar symptoms that she knows of.

She lives in a
<single-floor>
<apartment>
on the
<1st floor>
with her
<husband and children, aged 16, 18, 21>
<who are all in good health>
and
<no pets || a pet...>

She
<manages well at home || is able to ... but needs help with ...>
with
<no community care needed || community care of meals on wheels 2 times a week...>.

She maintains what she feels is a
<healthy || unhealthy>
though
<high in ... || low in...>
and exercises
<5>
times per week doing
<swimming>.

<Mrs. X>
currently
<does || doesn't>
smoke, and
<has never smoked. || has smoked>

If has smoked:
<5>
<cigarettes || cigars || chewing tobacco>
for the last
<15 years>.

<Mrs. X>
currently
<does || doesn't>
drink alcohol, and
<has never drank. || has drank>

If has drank:
<5>
<pints || vodkas || others...>
per
<week || month || year>
for the last
<15 years>.

She
<has || has not>
travelled abroad
to
<Singapore>

If immunizable complaint:
<was || was not>
immunized before leaving,
and
<no new symptoms || symptoms of>
while there.

Drug history

The medications she is on at the moment are:
<drug, dose>
for her
<disease>,

<No>
supplements, alternative medications, or recreational drugs.

<Is || is not>
taking
<OCP || HRT>.

<No allergies || allergic to things, drugs, dyes>
wth the reaction of
<reaction>.

Systems review

A review of systems was non-contributory.

Examination

On examination

Summary

In summary,
<Mrs. X>
is a
<60 year old>
woman with a
<12 hour>
history
of
<crushing substernal chest pain radiating down the L arm>
with positive risk factors of
<diabetes>,
<menopause>,
and
<high blood pressure>.

This is
<a classic case of || consistent with || my differential is>
<an acute MI>.

I would want to investigate with
<EKG, enzyme levels>
to look for
<...>
and my management plan would consistent of conservative treatment of
<rest, education>
and pending a worsening of symptoms, more invasive procedures such as
<CABG>.