iHuman Week 5 Felipe Garcia Case High Blood pressure

iHuman Week 5 Felipe Garcia Harvey Hoya Case High Blood pressure

57 y/o

5′ 9″ (175 cm)

195.0 lb (88.6 kg)

Reason for encounter

High blood pressure

Location

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

History Questions

How can I help you today?
What is your name?
How would you like to be addressed?
Is there anything I can do for you right now?
Do you have any other symptoms or concerns we should discuss?
How does this affect your life?
Did you or have your ever lost consciousness?

……
Physical Exams Required

Weight
Height
cognitive status
SpO2
temperature
blood pressure
pulse
respiration
…………….
Chief complaint: High blood pressure

Diagnosis: Hypertension primary (essential)

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

iHuman Case 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:
Start by asking two open-ended questions: “How can I help you today?” and “Any other symptoms or concerns?”
Next, obtain an HPI. Practice using the OLDCARTS method of documenting the HPI.
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.
Assessment:

Organize the Key Findings with the most important findings first and the least important findings last on the list.
Problem Statement:

The problem statement represents the NP’s evolving sense of the clinical picture. It must be sufficiently detailed yet precise and succinct (no more than 2-3 sentences).
Use professional language to summarize the patient’s current presentation. Include name or initials, age, chief complaint, pertinent positive and negative subjective findings, and pertinent positive and negative objective findings.
Test Results:

Review the test results (images and interpretation) provided.
Diagnosis:

Include the diagnosis for the patient.
Management Plan:

Using the expert diagnosis provided, create a comprehensive treatment plan using professional language. Use headings to address all six parts of the comprehensive treatment plan. If you do not wish to order an intervention for any part of the treatment plan, write “None at this time” but address each area. No intervention is self-evident. Provide a rationale and evidence-based in-text citation for each intervention. Include at least one appropriate, evidence-based, scholarly source to support your management plan decisions. Be sure to include the full reference for all in-text citations used. You will not be able to use italics for the title of your journal article within iHuman documentation.

Diagnostic tests: For the iHuman case studies, assume that the test results you reviewed in the case are those you ordered for your patient during this encounter and include them as part of the management plan. It is important to develop an appreciation for when, why, and how diagnostic tests are ordered. Provide a rationale for the tests ordered and reference citations.
Medications/treatments: Write out all medications like a prescription, including OTC medications. Include the name of the drug, dosage, route, frequency, duration, quantity to be dispensed, and refills. Include “continue other medications” if appropriate.
Consults/referrals: Provide a list of appropriate referrals if needed. Include a rationale for each and provide support from scholarly literature with an in-text citation.
Client education: Provide documentation of appropriate client education. Include a rationale and provide support from scholarly literature with an in-text citation.
Follow-up: Indicate the time interval when the patient should return (2 days, 1 week, etc.) and provide detailed symptomatology (“Red Flags”) indicating if the patient should return sooner or seek immediate attention.
Reference(s): Include at least one scholarly source per the NP Program Expectations for Scholarly Sources.

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