Case: Robert Jones

52 y/o

Reason for encounter

Elective total right knee arthroplasty.

Get all the history questions, physical exam, and complete EHR documentation.
Robert Jones, a 50 yrs old patient with total right knee arthroplasty due to chronic osteoarthritis.

Category

Details

Demographics

Name: Robert Jones

Age: 50 years

Sex: Not specified

Medical History

Chronic osteoarthritis, particularly severe in the right knee

Surgical History

Total right knee arthroplasty

Current Medications

Pain management medications (e.g., NSAIDs, opioids)

Possible medications for managing osteoarthritis symptoms (e.g., corticosteroids)

Laboratory Results

Possible elevated inflammatory markers (e.g., ESR, CRP)

Normal kidney and liver function tests (important for medication metabolism)

Imaging Studies

Pre-operative imaging showing severe osteoarthritis in the right knee

Post-operative imaging confirming successful placement of the knee prosthesis

Physical Therapy Notes

Progress in mobility and strength post-surgery

Any complications or difficulties in recovery

Follow-Up Appointments

Regular follow-ups with the orthopedic surgeon

Appointments with a physical therapist for rehabilitation

Directions: Review the iHuman Orientation Assignment directions in Canvas. As you progress through the Robert Jones iHuman Patient Encounter Practice Case, complete the iHuman Orientation Worksheet by finding the relevant information in the electronic health record (EHR), history, and physical. The information you collect on this worksheet will assist you in completing the iHuman Orientation assignment. The worksheet will not be submitted.

1) Key findings from Robert Jones’s EHR: Admitting Notes (Health Care Provider)

What is Mr. Jones’s Reason for the Encounter? Worsening pain over the last couple months despite being on pain medication. Pain awakes from sleep. Been sleeping in recliner most day due to pain. Was seen three days ago in surgeons’ office for pre op check in, labs and ECG
What is Mr. Jones’s age? 52 years old
What is Mr. Jones’s allergy? Shellfish
Does Mr. Jones have children? 29-year-old son
2) Key findings from Robert Jones’s EHR: Labs and Imaging/ECG

What is Mr. Jones’s blood type and screen? AB negative
Are there abnormal findings in the complete blood count? No abnormal findings.
What are Mr. Jones’s prothrombin time (PT) results? 15
What was Mr. Jones’s sodium? 135
3) Key findings during the Robert Jones’s health history

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