B. Patient Profile and History Patient Name: Shelley Age: 29 Weight: 60 Gender: M F Code Status: Full Chief Complaint: Confusion/Vomiting/Diarrhea History of Presenting Illness: Pt unable to give history. From boyfriend: Pt is 10 weeks pregnant. She started having vomiting and diarrhea yesterday evening. She thinks she saw some streaks of blood in her diarrhea. Explains that they had an argument yesterday because they have been stressed over this unplanned and unwanted pregnancy. They don’t live together. He left after lunch. She called at night to tell him she had vomiting and diarrhea, but told him not to come over because she was still upset. He came over to see how she was this morning. When he found her in bed, lethargic and confused, he called EMS. She did not complain of dysuria, frequency, fever. She noticed no vaginal bleeding. She had used alcohol and marijuana in the past but none in the last 4 weeks since she learned she was pregnant. Has been taking Prozac and a prenatal vitamin daily. Past Medical History: Anxiety/depression Medications: Fluoxetine Irritable bowel syndrome Pre-natal vitamins 1st trimester pregnancy Allergies: PCN C. Baseline Simulator State and Physical Exam No Monitor Display Monitor On, no data displayed Monitor on Standard Display HR: 130/min BP: 95/60 RR: 30/min O2SAT: 94% RA Rhythm: Sinus tach T: 37oC Glucose: 17.5 mmol/L GCS: 9 (E2 V2 M5) General Status: Toxic and unwell CNS: Lethargic and moaning. PERL 3mm. CVS: Tachycardic, heart sounds normal. RESP: Tachypneic, breath sounds normal. ABDO: Diffuse tenderness, no rigidity or guarding. MSK: Nil. SKIN: Scattered bruises Scenario States, Modifiers and Triggers Patient State Patient Status Learner Actions, Modifiers & Triggers to Move to Next State 1. Baseline State Rhythm: sinus tachycardia HR: 130/min BP: 90/60 RR: 28/min Drowsy. Moaning. Laboured breathing. Learner Actions - History & physical - Monitors - Ask for med list - Apply O2 - 2nd PIV Modifiers Changes to patient condition based on learner action O2 applied O2 SAT 96% Triggers For progression to next state
O2 SAT: 94% RA T: 37oC - 1-2L saline bolus - Tox/Abdo/G+S Bloodwork - B-HCG - Cap glucose - POCUS (IUP, no free fluid) - CXR/AXR - All actions complete or 5 min into case 2. Worsening hemodynamics 2. Worsening hemodynamics HR → 140 BP → 80/50 RR → 25 O2 SAT → 88% Breathing more labored. Becomes obtunded. **VBG result given at onset of state Learner Actions - Prepare for intubation - Fluid resuscitation - Push dose pressors - ± Start or prepare vasopressor infusion - Consider naloxone Modifiers - If not yet asked, boyfriend comes to room - If no intubation by 8 min, O2 SAT drops → 80% Triggers - Intubate 3. Persistent hypotension 3. Persistent hypotension HR → 110 BP → 80/55 RR → 12 O2 SAT → 96% Easy intubation. Sedated. Learner Actions - Call poison control - Start vasopressor or increase dose - Start chelation therapy - Prepare for whole bowel irrigation (insert OG) - Foley catheter - Post-intubation sedation - Heavy metal levels Modifiers - If not yet asked, boyfriend shows bag of meds (1 empty bottle of prenatal vitamins, full Prozac and herbal supplements) - Rest of bloodwork given - If called, Poison Control suggests deferoxamine at 15mg/kg/hr (may lower for hypotension) and whole bowel irrigation Triggers - Start chelation 4. Resolution 4. Resolution HR → 95 BP → 105/65 RR → 12 O2 SAT → 96% Sedated. Intubated. Ventilated. Learner Actions - Call ICU - Discuss psych assessment Modifiers Triggers - ICU called End of case Section VI: Scenario Progression Section VII: Supporting Documents, Laboratory Results, & Multimedia Laboratory Results VBG: pH 7.05/PCO2 38/PO2 80/HCO3 5 CBC: Hb 90/WBC 17/Plts 65 Lytes: Na 135/K + 4/HCO3 5/Cl 100/ Cr 130/Glucose 17 Lactate: 8