Kevin Dale

58 y/o

5′ 10″ (178 cm)

205.0 lb (93.2 kg)

Reason for encounter

Progressive dyspnea

Get all the history questions, physical exam, and complete EHR documentation.

Interview History Questions for Kevin Dale

What is your name?
How can I help you today?
Do you have any other symptoms or concerns we should discuss?
What has been happening since your last visit?
Do you have pain anywhere? If so, where?
What symptom is the most distressing for you?
Tell me how that makes you feel.
How does this affect your life?
What happened?
Are you coughing up blood
Do you have unusual heartbeats (palpitations)
Have you gained or lost weight unintentionally, despite normal appetite and exercise?
Have you noticed swelling in any part of your body
Do you have a cough
Do you have any other symptoms or concerns we should discuss
Do you have any pain in your chest
………….
Physical Exams Required

Weight
Height
cognitive status
SpO2
temperature
blood pressure
pulse
respiration
temperature
auscultate heart
auscultate lungs…….
Get all the complete Kevin Dale case with history questions, physical exam, complete EHR documentation, exercises, case findings, diagnosis, test results, and management plan.

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Differential Diagnoses

Below is an updated list of 20 differential diagnoses, with CHF as the lead diagnosis, and the “Must Not Miss” diagnoses clearly identified:

Congestive Heart Failure (Lead Diagnosis)
Acute Coronary Syndrome (Must Not Miss)
Pulmonary Embolism (Must Not Miss)
Ventricular Tachycardia, (Must Not Miss)
…………………
Required Tests

12 lead ECG
CBC
CMP
………..

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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