Week 5 ihuman
I. Focused Health History: Complete a focused health history. Scores
are automatically calculated within the i-Human platform when the
health history is submitted.
II. Focused Physical Exam: Complete a focused physical exam. Scores
are automatically calculated within the i-Human platform when the
health history is submitted.
III. EHR Documentation-Subjective Data: Document the history of
present illness (HPI) and focused review of systems (ROS).
Documentation must be:
I. accurate
II. detailed
III. written using professional terminology
IV. pertinent to the chief complaint
V. includes subjective findings only
IV. EHR Documentation-Objective Data: Document physical exam findings.
Documentation must be:
I. accurate
II. detailed
III. written using professional terminology
IV. pertinent to the chief complaint
V. include objective findings only
V. Problem Statement: Document a brief, accurate problem statement using
professional language. Include the following components:
I. name or initials, age
II. chief complaint
III. positive and negative subjective findings
IV. positive and negative objective findings
VI. Differential diagnosis (DDx): Select the most appropriate differential diagnoses
for the encounter. Your score will automatically calculate after the focused
physical exam is submitted.
VII. Differential diagnosis ranking: Rank the differential as lead and alternate
diagnoses
VIII. Must Not Miss: Identify the must not miss (MNM) diagnoses
IX. Diagnostic tests: Select the appropriate diagnostic tests for the virtual patient.
Once selected, review the results provided.
X. Management Plan: Use the expert diagnosis provided to create a pertinent
comprehensive evidence-based management plan. If a specific component of the
management plan is not warranted (i.e., no referrals are appropriate for the virtual
patient) document that no intervention is warranted. Include the following
components:
I. diagnostic tests
II. medications: write a specific prescription for each medication, including
over-the-counter medications
III. suggested consults/referrals
, IV. client education
V. follow-up, including time interval and specific symptomatology to prompt a
sooner return
VI. cite at least one relevant scholarly source as defined by program
expectations
reason for encounter:
-stomach really hurts
-can’t keep anything down
-hasn’t had BM x 2 days (normally once or twice/day)
-thinks it might be IBS (read online)
HPI:
-Patient c/o severe abdominal pain, nausea, vomiting, bloating, and
constipation.
-no known sick contact
-typically no issues with constipation
General:
-reports overall health has been good before this acute episode
-denies fevers
HEENT/Neck:
CV:
-denies palpitations, SOB, chest tightness/heaviness/pain
Resp:
-denies SOB
GI:
-reports severe abdominal pain that hurts more with palpation; pain is not
r/t eating, but does get full fast when she tries to eat; started as cramps,
now it feels like “squeezing” pain; no radiation of pain
-reports nausea, vomiting, bloating; eating induces vomiting; abdominal
pain feels better after vomiting
-reports she hasn’t had BM x 2 days (last BM was watery; she normally goes
once or twice/day)
-denies jaundice, heartburn, blood in stool
-reports no flatus for days
I. Focused Health History: Complete a focused health history. Scores
are automatically calculated within the i-Human platform when the
health history is submitted.
II. Focused Physical Exam: Complete a focused physical exam. Scores
are automatically calculated within the i-Human platform when the
health history is submitted.
III. EHR Documentation-Subjective Data: Document the history of
present illness (HPI) and focused review of systems (ROS).
Documentation must be:
I. accurate
II. detailed
III. written using professional terminology
IV. pertinent to the chief complaint
V. includes subjective findings only
IV. EHR Documentation-Objective Data: Document physical exam findings.
Documentation must be:
I. accurate
II. detailed
III. written using professional terminology
IV. pertinent to the chief complaint
V. include objective findings only
V. Problem Statement: Document a brief, accurate problem statement using
professional language. Include the following components:
I. name or initials, age
II. chief complaint
III. positive and negative subjective findings
IV. positive and negative objective findings
VI. Differential diagnosis (DDx): Select the most appropriate differential diagnoses
for the encounter. Your score will automatically calculate after the focused
physical exam is submitted.
VII. Differential diagnosis ranking: Rank the differential as lead and alternate
diagnoses
VIII. Must Not Miss: Identify the must not miss (MNM) diagnoses
IX. Diagnostic tests: Select the appropriate diagnostic tests for the virtual patient.
Once selected, review the results provided.
X. Management Plan: Use the expert diagnosis provided to create a pertinent
comprehensive evidence-based management plan. If a specific component of the
management plan is not warranted (i.e., no referrals are appropriate for the virtual
patient) document that no intervention is warranted. Include the following
components:
I. diagnostic tests
II. medications: write a specific prescription for each medication, including
over-the-counter medications
III. suggested consults/referrals
, IV. client education
V. follow-up, including time interval and specific symptomatology to prompt a
sooner return
VI. cite at least one relevant scholarly source as defined by program
expectations
reason for encounter:
-stomach really hurts
-can’t keep anything down
-hasn’t had BM x 2 days (normally once or twice/day)
-thinks it might be IBS (read online)
HPI:
-Patient c/o severe abdominal pain, nausea, vomiting, bloating, and
constipation.
-no known sick contact
-typically no issues with constipation
General:
-reports overall health has been good before this acute episode
-denies fevers
HEENT/Neck:
CV:
-denies palpitations, SOB, chest tightness/heaviness/pain
Resp:
-denies SOB
GI:
-reports severe abdominal pain that hurts more with palpation; pain is not
r/t eating, but does get full fast when she tries to eat; started as cramps,
now it feels like “squeezing” pain; no radiation of pain
-reports nausea, vomiting, bloating; eating induces vomiting; abdominal
pain feels better after vomiting
-reports she hasn’t had BM x 2 days (last BM was watery; she normally goes
once or twice/day)
-denies jaundice, heartburn, blood in stool
-reports no flatus for days
