Geisel School of Medicine Year 2 OSCEs Electronic Medical Record Updated 1.20.2015

• INSTRUCTIONS:
  Complete this template as you would complete the clinical write-up in On Doctoring. To type in each category, simply click in the box to type. The record is divided into three segments:
  
  Information
  I. Interview
  II. Physical Exam
  III. Problem List, Assessment & Plan
  
  To move throughout these segments, simply click on the bottom button "Next". The work will automatically save itself as you go.
  
  Once you have reviewed and corrected all information, please export the template by clicking "Export" on the last page, and clicking "Send", which will open up your email. Send this PDF to your small group facilitator(s) when you have finished. Late submissions will not be accepted. Your facilitator will grade the write-up using the rubric on Blackboard.

• Student Name

• Patient Name

• Conducted on

  Date

• Chief complaint (Cc): Mrs. Wilson is a 45 year old day care provider who complains of dyspnea upon exertion and left sided chest pressure radiating into the jaw

• HPI: Mrs. Wilson first experienced symptoms of dyspnea and left sided chest pressure while climbing up two flights of stairs two months ago. Since then she has continued to have episodes of chest pressure and dyspnea upon exertion with the most recent and notable attack occurring while raking leaves one month ago. During this episode the patient felt nauseated with pain radiating into her jaw. The pain in her chest is described primarily as pressure, as if force is being applied to the chest. Ceasing exertion is the only thing that alleviates her symptoms. Due to the increasing frequency of her episodes, Mrs. Wilson made a prior visit to her PCP and she was prescribed metropolol and sublingual nitroglycerin. The patient admits that she does not take the prescribed dose of her medications as metoprolol makes her feel "tired and light headed" and nitroglycerin " gives her a headache".

• Pertinent ROS: General: No rashes, lumps, sores, or dryness. Respiratory: Dyspnea upon exertion, no wheezing or cough Cardiovascular: Hypertension (see vitals), pressure on left side of chest radiating into jaw, no heart murmurs or gallops

• PMH: Patient does not state that she has any significant past medical history. However, she does remember that her last (total) cholesterol was "160" revealing possible hyperlipidemia.

• Medications: Metoprolol: 2 times a day by mouth Nitroglycerin: as needed sublingually

• Allergies/Adverse drug reactions: No known allergies Metoprolol: Patient feels tired and light headed after taking meds Nitroglycerin: Patient has a headache shortly after administration

• Social Hx: - Married - Day care provider

• Habits: 20 year smoking history though steadily reducing amount of cigarette use (first 1 pack, then half a pack, currently 5 cigarettes) - Mrs. Wilson expressed interest in quitting smoking and may need extra support (pharmacologic, or support group) to do so Exercise: none a part from work (daycare) and chores Diet: "Well-balanced"

• Preventative Health: Total cholesterol was reported by the patient to be 160

• Family Hx: Father survived a myocardial infarction at 58

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• Pt Description: Mrs. Wilson is a thin and well-appearing 45 year old day care provider

• Vital Signs: BP: 152/90 HR: 82 RR: 20 Temperature: 36.8

• Physical Exam Findings: General: alert, oriented, and good hygiene Skin: warm and dry, no rashes or nail abnormalities Heart: No arrhythmia, bruits, gallops, murmurs or rubs Carotids: normal upstroke and equal amplitude Lungs: symmetrical chest expansion and diaphragmatic excursions. Patient was breathing comfortably without use of accessory muscles. Lungs were clear to auscultation

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PROBLEM LIST & SUMMARY STATEMENT

• Problem List: - Dyspnea upon exertion - Left sided chest pain, radiating into the jaw - Hypertension - Possible hyperlipidemia

ASSESSMENT: Mrs. Wilson is a 45 year old day care provider who came in with a chief complaint of dyspnea upon exertion beginning two months ago, left sided chest pain radiating into the jaw with a previous atypical angina episode notable for nausea. She has no significant past medical history but her family history is remarkable with her father surviving a heart attack at age 58.

• Most likely Dx (include reasoning): Stable Angina => dyspnea and angina only during exertion and not increasing in intensity or frequency. Family history of cardiac events (MI), lack of exercise, smoking history, and high cholesterol and high blood pressure are all also risk factors that would contribute to cardiovascular disease

• Alternative Dx considerations: Anemia Neoplasm Gastrointestinal pain

PLAN Mrs. Wilson should undergo a cardiac stress test, ECG, lipid panel, and possibly a coronary arteriography to fully assess her cardiovascular risk. Mrs. Wilson should also be educated and supported on her smoking cessation and other lifestyle changes like increasing exercise and a low fat diet. Current medications should also be reassessed as the side effects are playing a role in lack of adherence.

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