Ebony Gray week 1 case 1

WEEK 1 CASE 1!!! Grading Rubric 1. 40% = History questions 2. 30% = physical exam 3. 10% = differential diagnosis list 4. 10% = ranking the differential diagnosis 5. 10% = lab test 6. 0% = science exercises 7. 0% = management plan – faculty scores this. Case Help HISTORY:  Patient interview reminder sheet- document in key findings  “Good Question” means you asked a required question Step 1: Start by asking 2 open ended patient centric questions: 1. How can I help you today? 2. Any other symptoms or concerns? Step 2: Obtain an HPI using “OLDCARTS”  = Onset, circumstances surrounding start of symptom  L = Location, radiation  D = Duration  C = Characteristics (sharp, dull, cramping)  A = Aggravating  R = Relieving  T = Treatments  S = Severity Step 3: PMH  No patient record – Obtain history  Have patient record – Update allergies, medications, OTC drugs Step 4: FH  No patient record – Obtain history Step 5: SH  No patient record- obtain history  Have patient record- Update if major changes in living situation, death of partner, loss of job etc. Step 6: ROS  Questions for systems not addressed in HPI  Choose ROS for the body systems you do not have information on. Use the large multipart questions Physical Exam  Do those physical assessment maneuvers as needed  Choose ROS for those body systems you do not have information on. Use large multipart questions. Assessment  Organize key findings list by selecting the MSAP (Most significant active problem).  Mark other findings as; related, unrelated, unknown, PMH/resolved. Problem Statement  Short summary of patient’s presentation. Should contain: 1. Demographic description, 2. Chief complaint, 3. Hx and PE key findings, 4. Risk factors. Keep it concise. Differential Diagnosis  List disease you are considering Prior to ordering tests. Tests:  Determine what tests are needed to rule in or rule out each diagnosis on authors corrected list.  Review authors corrected list of test results. Final Diagnosis  Select a final diagnosis or diagnoses. Treatment plan  Write a treatment plan following your instructors’ guidelines. Gear head exercises  Complete exercises found throughout the case (look for the brain with gears icon in steps of the case) Summary  Proceed all the way to the “Summary” tab.  Submit your case and press the “see evaluation” button to see your first evaluation