Stefon Owens, Roger Miller, Jose Gonzalez

Age: 42 y/o

Height: 7’1”

Weight: 180lbs

Reason for encounter: diarrhoea

Get all the history questions, physical exam, and complete EHR documentation.
HISTORY QUESTIONS (SUBJECTIVE):

How can I help you today? I have had terrible diarrhea I just feel wiped out!
Do you have any other symptoms or concerns? We should discuss? Well, I have a headache. Also, my mouth feels like someone stuck a bunch of cotton in it.
Is there any blood in your stools or with your bowel movement?. Yes, I started seeing blood in the toilet. It’s really more like streaks of blood in with the diarrhea. That scared me a bit and so I finally thought I ought to come in.
Do you have nausea and or vomiting? Only very mildly nauseated. But not worth talking about. It’s not really a problem I haven’t thrown up at all.
Do you have any pain in your abdomen? Yes, my whole stomach feels sore and crampy.
When did your abdominal pain start? Just before the diarrhea episodes but now it is sore all the time.
Does the pain in your abdomen radiate someplace else? Where? No.
……..Get all history questions
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Required Physical Exams

Auscultate abdomen
Auscultate heart
Auscultate lungs
Examine pupils
Inspect mouth/pharynx
Inspect…..
Get all required physical exams for the case
Test Results

BMP: BUN 26-elevated

C.Diff: negative

Colon Biopsy: cancelled because of ID of infectious etiology

CBC: WBCs 13,500-elevated

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Complete the following components in the i-Human Virtual Patient Encounter for the required case addressing the Cardiovascular system.

Focused Health History
Complete a focused health history. Scores are automatically calculated within the i-Human platform when the health history is submitted.
Focused Physical Exam
Complete a focused physical exam. Scores are automatically calculated within the i-Human platform when the health history is submitted.
EHR Documentation-Subjective Data
Document the history of present illness (HPI) and focused review of systems (ROS). Documentation must be:
accurate
detailed
written using professional terminology
pertinent to the chief complaint
includes subjective findings only
EHR Documentation-Objective Data
Document physical exam findings. Documentation must be:
accurate
detailed
written using professional terminology
pertinent to the chief complaint
include objective findings only
Problem Statement
Document a brief, accurate problem statement using professional language. Include the following components:
name or initials, age
chief complaint
positive and negative subjective findings
positive and negative objective findings
Differential diagnosis (DDx)
Select the most appropriate differential diagnoses for the encounter. Your score will automatically calculate after the focused physical exam is submitted.
Differential diagnosis ranking
Rank the differential as lead and alternate diagnoses
Must Not Miss
Identify the must not miss (MNM) diagnoses
Diagnostic tests
Select the appropriate diagnostic tests for the virtual patient. Once selected, review the results provided.
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:
diagnostic tests
medications: write a specific prescription for each medication, including over-the-counter medications
suggested consults/referrals
client education
follow-up, including time interval and specific symptomatology to prompt a sooner return
cite at least one relevant scholarly source as defined by program expectationsLinks to an external site.
Click “Submit” once the case is complete and Download the i-Human Virtual Patient Encounter report.
Reflection
Address the following questions:

How would your treatment plan change if your client admitted to food insecurity? What resources are available in your community that would be useful for senior citizens experiencing food insecurity and dietary restrictions based on medical diagnoses?
write 150-300 words in a Microsoft Word document
demonstrate clinical judgment appropriate to the virtual patient scenario
cite at least one relevant scholarly source as defined by program expectations
communicate with minimal errors in English grammar, spelling, syntax, and punctuation

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