Preparing the Assignment

Follow these guidelines when completing each component of the assignment. Contact your course faculty if you have questions.

1. General Instructions

Access i-Human by clicking the link below. Click the blue bar to launch the activity in a new browser window. The case does not need to be completed in one sitting; it can be re-entered at the same case location at a later time.

Select the i-Human Virtual Patient Encounter that best aligns with the body system of one of the areas of opportunity you have identified from your CEA Pre-Diagnostic Exam taken in NR603. Access ONLY ONE of the i-Human cases for this assignment by clicking the link provided in the i-Human Case Links module.

All graded case documentation, including the Management Plan, must be completed within the i-Human platform. Follow the i-Human Documentation Guide Download i-Human Documentation GuideOpen this document with ReadSpeaker docReaderto complete your client’s electronic health record (EHR) and management plan. Use current APA Style Standards to format citations and references in the management plan and reflection. Use https://apastyle.apa.org/Links to an external site. and APA Academic WriterLinks to an external site. for formatting and grammar assistance.

2. Include the Following Sections (detailed criteria listed below and in the Grading Rubric):

Complete the following components in the i-Human Virtual Patient Encounter for the required case.

1. Focused Health History
   • Complete a focused health history. Scores are automatically calculated within the i-Human platform when the health history is submitted.
2. Focused Physical Exam
   • Complete a focused physical exam. Scores are automatically calculated within the i-Human platform when the health history is submitted.
3. EHR Documentation-Subjective Data
   • Document the history of present illness (HPI) and focused review of systems (ROS). Documentation must be:
     1. accurate
     2. detailed
     3. written using professional terminology
     4. pertinent to the chief complaint
     5. includes subjective findings only
4. EHR Documentation-Objective Data
   • Document physical exam findings. Documentation must be:
     1. accurate
     2. detailed
     3. written using professional terminology
     4. pertinent to the chief complaint
     5. include objective findings only
5. Problem Statement
   • Document a brief, accurate problem statement using professional language. Include the following components:
     1. name or initials, age
     2. chief complaint
     3. positive and negative subjective findings
     4. positive and negative objective findings
6. Differential Diagnosis (DDx)
   • Select the most appropriate differential diagnoses for the encounter. Your score will automatically calculate after the focused physical exam is submitted.
7. Differential Diagnosis Ranking
   • Rank the differential as lead and alternate diagnoses
8. Must Not Miss
   • Identify the must not miss (MNM) diagnoses
9. Diagnostic Tests
   • Select the appropriate diagnostic tests for the virtual patient. Once selected, review the results provided.
10. 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:
      1. diagnostic tests
      2. medications: write a specific prescription for each medication, including over-the-counter medications
      3. suggested consults/referrals
      4. client education
      5. follow-up, including time interval and specific symptomatology to prompt a sooner return
      6. cite at least one relevant scholarly source as defined by program expectations
    • Click ”Submit” once the case is complete and Download the i-Human Virtual Patient Encounter report.
11. Reflection

• • Address the following questions:
    1. How did the i-Human Virtual Patient Encounter case help strengthen your understanding of the chosen body system?
    2. What additional study techniques will you incorporate to strengthen your understanding of the chosen body system?
  • Include the following components:
    1. write 150-300 words in a Microsoft Word document
    2. demonstrate clinical judgment appropriate to the virtual patient scenario
    3. cite at least one relevant scholarly source as defined by program expectations
    4. communicate with minimal errors in English grammar, spelling, syntax, and punctuation
    5. Reflection must be your original work and may not be re-used from prior coursework.

Submit both the i-Human Virtual Patient Encounter report and your completed reflection WORD document to the Week 2 dropbox.

Solution

Comprises of

Subjective History

1. How can I help you today?
   Well, I have been unusually tired recently and a bit short of breath, but I just thought I was overworking. Then today I was out working in the yard and got extremely lightheaded. I felt like I was about to pass out and I think if I hadn’t sat down, I actually might have passed out. I wasn’t doing anything strenuous…just planting some flowers.
2. Do you have any other symptoms or concerns we should discuss?
   Yes, more and more frequently I’ve been getting lightheaded. Oh, I also am getting headaches. I used to never get headaches, so all of this is new for me. I just thought I was out of shape and working too hard. That’s all I can think of this minute.
3. When did you first notice feeling short of breath?
   Several months ago. I thought it was just getting older.
4. Does anything make your shortness of breath better or worse?
   It did get better when I sat down. It’s worse with house and yard work now.
5. How severe is your shortness of breath?
   I have not been able to do routine things without getting short of breath.
6. Do you have a cough?
   No.
7. Do you wheeze?
   No.
8. Are you short of breath when lying down?
   No.
9. What are the events surrounding the start of your fatigue/tiredness?
   I first noticed feeling tired during a round of golf several months ago. I had to stop walking after the first nine holes and finish the round with a cart. Now that had never happened to me before. Again, I just thought I was working too hard.
10. When did your fatigue/tiredness start?
    Several months ago.

Labs:

• CBC
• Vit B12
• Ferritin Blood……….

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