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Performance Overview for Elke Guerrero on case Felipe GarciaPerformance Overview for Elke Guerrero on case Felipe Garcia
The following table summarizes your performance on each section of the case, whether you completed that section or not. Time spent: 3hr 30min 45secTime spent: 3hr 30min 45sec Status: SubmittedStatus: Submitted Case SectionCase Section StatusStatus YourYour ScoreScore Time spentTime spent Performance DetailsPerformance Details Total Score 65% History Done 84% 43min 14sec 114 questions asked, 10 correct, 2 missed relative to the case's list Physical exams Done 37% 35min 10sec 60 exams performed, 17 correct, 1 partially correct, 25 missed relative to the case's list Key findings organization Done 1min 46sec 10 findings listed; 11 listed by the case Problem Statement Done 2min 47sec 39 words long; the case's was 84 words Diagnosis Done 100% 33sec Management Plan Done 16min 54sec 200 words long; the case's was 280 words Exercises Done 43% (of scored items only) 4min 56sec 0 of 1 correct (of scored items only) 1 partially correct
History Notecard by Elke Guerrero on case Felipe GarciaHistory Notecard by Elke Guerrero on case Felipe Garcia
Use this to collect your thoughts to develop a differential diagnosis list. Step 1: Write symptoms (SxSx) you have identified in the appropriate column and row. Step 2: Characterize the symptoms using "OLDCARTSOLDCARTS" (ie., OOnset, LLocation, CCharacteristics...etc) in the HPI section. Step 3: Record your thoughts in the space labeled "What this meansWhat this means". Is the disease acute or chronic? Infectious or other?... Timing/treatments
Hx Categories Hx Categories Sx=Sx= Sx=Sx= Sx=Sx= Sx=Sx= Sx=Sx= Sx=Sx=
CC CC Provided
How can I
help you?
Any other
symptoms?
HPI HPI Onset/events
Location
Duration
Characteristics
Aggravating
Reliving
Severity
What this means What this means
Management Plan by Elke Guerrero on case Felipe GarciaManagement Plan by Elke Guerrero on case Felipe Garcia
- Diagnostic tests Blood tests including CBC (to check for anemia and blood disorders), BMP (to assess kidney function and eletrolytes), lipid profile for cholesterol & tryglycerides, thyroid function tests to rule out thyroid disorders which can trigger secondary hypertension Urinalysis to check for kidney damage ECG to identify any cardiac abnormalities
- Medications Lisinopril Tablet 10 mg One tablet PO once daily Dispense 30 tablets 2 refills Take one tablet by mouth once daily at the same time with or without food
- Consults/Referrals Nutritionist- Diet canceling and weight management to improve cardiovascular health Smoking cessation
- Client Education Educate patient on hypertension diagnosis, importance of medication adherence, smoking cessation, weight loss, and potential complications Provide education on lifestyle modifications such as heart-healthy diet, reducing sodium intake, regular exercise, and smoking cessation Teach how to measure and monitor blood pressure at home and keeping a log of readings Educate on warning signs of cardiovascular events such as chest pain, severe headache, and dizziness and how to seek immediate help
- Follow up schedule a 2-week follow-up visit to assess management of blood pressure Regular visits bi-annually to assess progress Annual exam and ECG to monitor progress and any complications
Electronic Health Record by Elke Guerrero on case Felipe GarciaElectronic Health Record by Elke Guerrero on case Felipe Garcia
History of Present IllnessHistory of Present Illness
CategoryCategory Data entered by Elke GuerreroData entered by Elke Guerrero Reason for Encounter High blood pressure History of present illness Patient was told in a community clinic recently that he had blood pressure of 170/ and needed follow-up. He was warned about diet changes years ago because his blood pressure was elevated but the patient has not been compliant. Patient denies any associated symptoms and has no idea when his high blood pressure started.
Past Medical HistoryPast Medical History
CategoryCategory Data entered by Elke GuerreroData entered by Elke Guerrero Past Medical History Patient has history of right knee injury with ACL repair done years ago. History of acid reflux managed with omeprazole. Has achy knees. Hospitalizations / Surgeries ACL reconstruction years ago
MedicationsMedications
CategoryCategory Data entered by Elke GuerreroData entered by Elke Guerrero Medications Ibuprofen 200 mg 2-4 tablets in the mornings and PRN for achy knees Omeprazole for acid reflux
AllergiesAllergies
CategoryCategory Data entered by Elke GuerreroData entered by Elke Guerrero Allergies NKDA
Preventive HealthPreventive Health
CategoryCategory Data entered by Elke GuerreroData entered by Elke Guerrero Preventive health No pneumovax vaccine No current GP No regular physical assessment
Physical ExamsPhysical Exams
CategoryCategory Data entered by Elke GuerreroData entered by Elke Guerrero General Patient appears tired and is overweight. No fever, general weakness, or chills. Skin Skin is warm and dry. Back of hand skin snaps back rapidly, showing normal turgor and rigidity HEENT / Neck Head is atraumatic and normocephalic. Facial features are symmetric, no deformities, and temporal arteries are non-tender. No edema, redness, or discharge from eyes. 20/20 vision acuity. Ears have no erythema, no cauliflower, or discharge. No crowding of posterior oropharynx, no lesions in the mouth. No nasal discharge or postnasal drip. Trachea is midline, no neck swelling, and Jugular vein pressure is 2 cm from sternal angle with head elevated to 30 cm. Cardiovascular No localized tenderness, heaves, and lifts in anterior and posterior chest. Chest expansion equal bilaterally. No paplpitations or murmurs. No peripheral edema. Capillary refill less than 3 seconds. No accentuated sounds at the PMI/apex. Chest / Respiratory Equal chest expansion bilaterally. No wheezing. Normal breath sounds present. Abdomen Abdomen is protruberant. Waist circumference is 45 cm. Normoactive bowel sounds on all quadrants. No erythema, masses, or moles. Margins of aorta 2cm by palpation. No tenderness or masses palpable. Genitourinary / Rectal Exam not performed Musculoskeletal / Osteopathic Structural Examination Full range of motion on all extremities. No joint tenderness. Knees have no masses or joint tenderness. Maintains an upright posture. Neurologic Alert and oriented x 4. No numbing or tremors. Reflexes 2+ bilaterally on all extremities. Psychiatric 3/3 registration and recall. Alert and oriented x4. Spatial and executive function intact. Able to follow multi-step commands. Lymphatic No swollen lymph nodes
