NR509 Week 2 Case: Practice Case Marvin Webster

NR509 Week 2 Case: Practice Case Marvin Webster

Marvin Webster

18 y/o

6′ 0″ (183 cm)

185.0 lb (84.1 kg)

Reason for encounter

Fatigue and cough

Location

Outpatient clinic with x-ray, ECG, and laboratory capabilities

Case Instructions

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This is a graded practice case. You have up to 5 attempts, and the final one you complete will be the graded one.

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:
  1. Start by asking two open-ended questions: “How can I help you today?” and “Any other symptoms or concerns?”
  2. Next, obtain an HPI. Practice using the OLDCARTS method of documenting the HPI.
  3. 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 abnormal findings under Key Findings. All documentation MUST be completed in the EHR within the iHuman 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.

Solution for NR509 Week 2

History:
How can I help you today? “I feel awful…I’m exhausted. I have a cough and body aches”
Do you have any other symptoms or concerns we should discuss? “my throat is sore, and I have
a headache”
Do you have any allergies?
Are you taking any prescription medications?
Are you taking OTC or herbal medications?
Have you had your flu shot this year?

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