NR509 Week 6 iHuman: Perry Soloman

Case Instructions

History:

You may ask up to 120 questions but must determine relevant questions. Questions should be focused on the present illness and associated body systems. More questions do not earn more credit.
All documentation MUST be completed in the Electronic Health Record (EHR) within the Human Virtual
Patient Encounter.
Findings do not auto-populate in the EHR.
Document information in the appropriate EHR sections of the patient history and enter abnormal findings under Key Findings.
Document subjective information ONLY in the history.
Suggested approach:
Start by asking two open-ended questions: “How can I help you today?” and “Any other symptoms or concerns?”
Next, obtain an HPI. Practice using the OLDCARTS method of documenting the HPI.
Obtain previous medical history, family history, social history, and review of systems. Document as appropriate within the EHR in the platform.

Physical Exam:

Open and view the patient’s record to receive credit for obtaining vital signs.
Click on appropriate physical exams of the present illness and associated body systems to determine findings for the patient.
Document physical exam information in the EHR in the appropriate sections of the Physical Examination and enter ahnormal findinne under Kev Findinne All dormentation MI IST he comnlated in the FHR

History Feedback

Ask relevant problem-focused questions to create an accurate initial differential diagnosis list. Various questions may yield the same information. Examples of high-yield questions for this case include:

• Performed X Missed

Pivotal Concept Addressed	Category	Question	Response
•	HPI	How can I help you today?	I’ve been having these really bad headaches over the last few months. I don’t have one now, and haven’t had one in about a week, but I thought I’d have it checked out anyway.
•	HPI	Do you have any other symptoms or concerns we should discuss?	Just the symptoms that I always have had with these headaches, like nausea and vomiting. There’s nothing else I can think of off the top of my head.
•	HPI	When did your headache start?	They have gotten worse over the last few months.
•	HPI	What are the events surrounding the start of your headache?	In the past, they were much less frequent and they felt more like I had the hat from hell strapped to my head. These ones feel bad but a little different than that. They might correlate with stress. I have had a lot going on lately.
•	HPI	How long does your headache last?	It’s not always the same, but they can last the whole day, like 15 hours.
•	HPI	Does your headache come and go?	Yeah, I’m super glad they’re not constant.
•	Symptom	Do you have new headaches that you have not experienced previously?	Maybe? I don’t know. There’s definitely some cross over. I have been having these headaches every 1-2 months for the past ten years, but the past few months they’re happening more frequently, like every 1-2 weeks, which is why I’m here. The pain is also worse.

Physical Exam Feedback

• Performed Correctly & Partially Correct
Preferred Exams	My Exams	Feedback TE
• blood pressure	• blood pressure	• Performed Correctly
• pulse	• pulse	• Performed Correctly
• respiration	• respiration	• Performed Correctly
• temperature	• temperature	• Performed Correctly
• assess stance & gait	• assess stance & gait	• Performed Correctly
• inspect/palpate head (including scalp)	• inspect/palpate head (including scalp)	•Performed Correctly
• palpate sinuses	• palpate sinuses	• Performed Correctly
• test visual acuity	• test visual acuity	• Performed Correctly
• inspect eyes	• inspect eyes	• Performed Correctly