II. EHR Documentation (Subjective Data): Document the history of present illness (HPI) and focused review of systems (ROS) including subjective data only Documentation must be:
I. accurate
II. detailed
III. written using professional terminology
IV. pertinent to the chief complaint
III. EHR Documentation (Objective Data): Document physical exam findings including objective findings only, Documentation must be:
I. accurate
II. detailed
III. written using professional terminology
IV. pertinent to the chief complaint
IV. Key Findings/Most Significant Active Problem: Document key findings from the history and physical exam in the Assessment tab of the case.
i. Identify the most significant active problem (MSAP) and the relation of other key findings to the MSAP
V. Problem Statement: Document a brief, accurate problem statement using professional language. Include the following components:
I. name or initials, age
II. chief complaint
III. positive and negative subjective findings
IV. positive and negative objective findings
VI. Management Plan: 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:
I. diagnostic tests
II. medications: type a specific prescription for each medication, including over-the-counter medications
III. suggested consults/referrals
IV. client education
V. follow-up, including time interval and specific symptomatology to prompt a sooner return
VI. at least one relevant scholarly source and provide rationale for interventions as defined by program expectations
VII. Reflection: Address the following question: What are the “red flags” in this case? Based on your pertinent key findings, what is “the worst-case scenario”? What lessons did you learn from this case that you can apply to your future professional practice? Include the following components:
I. type 150-300 words in a Microsoft Word document
II. demonstrate clinical judgment appropriate to the virtual patient scenario
III. cite at least one relevant scholarly source as defined by program expectations
IV. communicate with minimal errors in English grammar, spelling, syntax, and punctuation
CHIEF COMPLAINS
Patient alert and oriented x4
Temp 37.0(98.6F oral)
Pulse 80bpm regular normal
B/P 124/82 normotensive, Norma RIGHT AND LEFT
Respiration 14 regular unlabored
SPO2 97%
Patient is 22-year-old female
Height 5, 7(67cm)
Weight 118.0 LB (53.6kg)
BMI 18.4
Throbbing Headaches start yesterday- 1 day
Have has this current attack for more than a day/ for 30 hours
Felt it deep inside, precisely temporal and radiate all over r
Patient is getting it more often that usually lately every 4 to 6 weeks and it’s getting progressively worst
Rating 8/10 and happens more often
Start gradually and get progressively worst
Had same issue last year with an aura seeing flashes of light 20 minutes prior the attack
Patient currently had problem seeing certain direction due to this headache
No aura notices with this current attack
Patient taking 2 Tylenol q 4 hour for headache with no significant effect
Patient feels nauseated and loud noise bother her
Caffeine makes it worst
Has past history of headache stomach unsettled patient cannot eat
No trauma to head
Patient on birth control pill
Patient Tylenol and multivitamin
Flu shot every year up to date and tetanus shot 5 years ago
Just feel stress and wish to have more sleep
Usually 2 types of headaches, one minor that goes away with Tylenol and another major that is resistant to Tylenol
Patient is experiencing major currently staying in the dark quite room helps
Sister and mother have had headache but most often and severe is sister
Father 50years with high blood pressure issues
Mother 49
Sister 20 with frequent headache
Brother 15 is fine
Usually, to take alcohol 1 or 2 drink on weekend night or bar drink
Struggles with college weight gain due to junk food and lack of exercise
Childhood illness of chicken pox and mono resolved
Patient anxious to get better to write school work paper for final exam
Patient just broke up with boyfriend
She admitted been stress
