NR509 Week 6 Case: Kathleen Parks

100% accurate key questions, physical assessment activities, EHR, and management plan.

Case Instructions

CASE PLAY INSTRUCTIONS AND HELP

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 iHuman 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 intormation in the CHR in the appropriate sections of the Physical Examination and enter abnormal tindings under Key Findings. All documentation MUST be completed in the EHR within the Human Virtual Patient Encounter.
Document objective information ONLY in the Physical Exam.
Avoid ambiguous terms like “normal”. What is normal? Document what you found; interpret the findings later when you begin diagnosing the findings.
If you did not assess a body system, document “Not assessed” rather than “Negative”. You do not want to infer findings that you did not assess inadvertently.

Assessment:

• Organize the Key Findings with the most important findings first and the least important findings last on the list.

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?	l’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……………………………$25