Matt Gilchrist had a registrar write these up once, and has used these case studies in the training of other Registrars.
These are all fabricated cases, and are meant to utilise much of the clinical software. Each resultant set of notes should be reviewed for accuracy.
Mrs Fake Patient, a 30yo female (DOB 12/6/198X) is coming to see you for the first time. Her LMP was 2 months prior (5/28 cycle), and a home pregnancy test is positive. She has recently moved with her partner and children from another town. she is G4P2M1. She does not currently have any abdominal pain, PV discharge or bleeding.
PMHx is significant for epilepsy, depression and migraines. She also had a RLL pneumonia last year. This year she received a fluvax needle and the pneumococcas vaccine in March at Toowoomba.
She has an allergic reaction of urticaria and perioral swelling if she eats walnuts. Other nuts are ok.
Medications: Phenytoin 500mg TDS, cipramil 20mg mane, paracetomol PRN, womens multivitamin supplement.
Social history: she works as a child care worker at the local day care centre. She lives with her partner and 2 children in Goondiwindi. She enjoys lawn bowls and social tennis, and DVD boxed sets of the vicar of Dibley. She stopped smoking a month ago when she missed her first period. Prior to this she smoked 10 cigarettes per day. She is a social drinker of 3-4 drinks on the weekend. She is concerned about weight gain during this pregnancy
On examination she is an obese lady, weight 100kg, height- 1.70cm. HR- 74pm, BP- 126/86, RR 16. Abdomen is soft, and non tender. BS present. You cannot detect a fundal height.
A urine dipstick is positive for leuks and small blood.
Update her chart for her PMhx and Medications, immunisations, social history and examination.
Update her obstetric history.
Calculate her BMI.
Calculate her estimated due date, and order appropriate antenatal investigations (bloods, USS, ?PAP).
She thinks her blood group is AB negative. Create an alert for her to remind you to give anti-D during pregnancy and postnatally.
You will also need to prescribe her folate, iron supplements and her regular medications.
Given her pregnancy, change her antiepileptic from phenytoin to an equivalent dose of a safer medication (they should change to sodium valproate)
Make a refferal to the dietician for advice on antenatal nutrition.
Provide her with an information sheet on weight gain during pregnancy
Mrs FP also requires a medical certificate for today.
Mrs FP has also brought her grandmother, Older Patient to see you
OP is a 83 yo lady (DOB- 06/06/192X).
OP previously lived in Armidale, but was not coping well at home so has moved to Goondiwindi to live in FP’s granny flat. She has an extensive medical history. She is a poor historian and becomes confused and easily distracted during your consultation. She reports frequent burning and stinging with urination. She has also lost all of her previous scripts in the move. She is a non-smoker/ non-drinker who enjoys yoga, paint by numbers and jigsaw puzzles.
FP pulls out a tattered letter from OP’s previous GP
Thank you for your ongoing care of this pleasant lady.
Past medical history: Bipolar disorder, Alzheimers dementia (mild), urge incontinence, osteoporosis, recurrent small bowel obstruction secondary to adhesions (surgical admission to St Andrews hospital in march 2008), Insulin dependent diabetes. She had a displaced colles fracture of the left wrist following a fall May 2009.
No known drug allergies
Aricept 10mg BD
Olanzipine 5mg BD
Metformin 1g TDS
Lantus 44U nocte
Novorapid 12U TDS with meals
Caltrate 600mg TDS
Ramipril 5mg mane
Oxycontin SR 20mg BD
Update her medical record
Write her new Prescriptions, including authority scripts.
Generate a mental health plan for Mrs OP
Generate a health assessment
Baby patient is a 12month old infant who presents with his mother for a check up. He has been seen at the practice before, but alas, has not ahd his record updated. He received his 6 month immunisations at the Boggabilla clinic. He requires his 12 month needles today. Mum is also concerned that he may be allergic to medicine as he broke out in a rash when given amoxill for a UTI 3 months ago. Mum says he often has temps and that the nurse in Bogga says “his wee stick lights up like a Christmas tree” all the time. On examination he is a happy baby (until you jab him with lots of needles!), with no obvious signs of distress. His weight is 11.6kg. He is the youngest of 7 siblings. Mum is also worried that he gets ear and chest infections “all the time”.
Update his medical record.
Record any allergies or suspicions of allergies
You are concerned about recurrent UTI in this infant. Order appropriate investigations (urine MCS, USS renal tract) and refer to a paediatrician in Toowoomba. They would like to see a private specialist.