ihuman Reflection

Report generated on 1/16/2025, 12:29:10 AM America/New_York

Performance Overview for Esther Serwaa Adjei on case Marvin Webster

The following table summarizes your performance on each section of the case, whether you completed that section or not.

Time spent: 9hr 35min 10sec Status: Submitted

Case Section Status Your Score

Time spent Performance Details

History Done 78% 2hr 43min 12sec

62 questions asked, 7 correct, 2 missed relative to the case's list

Physical exams

Done 89% 27min 18sec

182 exams performed, 13 correct, 2 partially correct, 0 missed relative to the case's list

Key findings organization

Done 2min 23sec

6 findings listed; 9 listed by the case

Problem Statement

Done 57min 45sec

78 words long; the case's was 68 words

Diagnosis Done 100% 9sec

Management Plan

Done 2hr 24min 7sec

444 words long; the case's was 117 words

Exercises Done 67% (of scored items only)

2min 51sec

0 of 1 correct (of scored items only) 1 partially correct

Attempt: 3399533

Report generated on 1/16/2025, 12:29:10 AM America/New_York

History Notecard by Esther Serwaa Adjei on case Marvin Webster

Use this worksheet to organize your thoughts before developing a differential diagnosis list.

1. Indicate key symptoms (Sx) you have identified from the history. Start with the patient's reason(s) for the encounter and add additional symptoms obtained from further questioning.

2. Characterize the attributes of each symptom using "OLDCARTS". Capture the details in the appropriate column and row.

3. Review your findings and consider possible diagnoses that may correlate with these symptoms. (Remember to consider the patient's age and risk factors.) Use your ideas to help guide your physical examination in the next section of the case.

HPI Sx = Sx = Sx = Sx = Sx = Sx = Onset

Location Duration

Characteristics Aggravating

Relieving

Timing / Treatments

Severity Attempt: 3399533

Report generated on 1/16/2025, 12:29:10 AM America/New_York

Problem Statement by Esther Serwaa Adjei on case Marvin Webster

Marvin Webster is an 18year old college student with a PMH of childhood asthma and currently not receiving treatment for it. Denies any allergy to drugs or food. Presents to the clinic today with complaints of malaise, sore throat, dry cough and dry cough. Patient expressed that his symptoms started about 2weeks ago, which symptoms got better and returned about 4days ago. physical examination reviewed temperature of 101 F - oral, with a stable blood pressure and BMI.

Attempt: 3399533

Management Plan by Esther Serwaa Adjei on case Marvin Webster

SUBJECTIVE:

Patient's chief complaint: Marvin Webster presents to the clinic with complaints of headache, dry cough, chills and fatigue.

Allergy: Denies any drug or food allergy. PMH: Childhood asthma Medications: Over the counter ibuprofen and cough syrup. Social history: Occasional wine drinker, denies illicit drug usage and tobacco

ROS: General - headache, dry cough, myalgia, fatigue and sore throat. Skin, hair, nails - intact, no abnormal changes Head/neck - complaints of headache, denies lightheadedness and dizziness. Eyes - vision intact, denies eye pain, redness. Ears - complaints of right ear pain, no abnormal discharge. Nose - Denies any sneezing or nosebleeds. Throat/Mouth - complaints of sore throat, denies difficulty swallowing and hoarseness Lymphatic - Denies any lumps or pain. no history of thyroid diseases. Chest/Lungs: Nonproductive dry cough and denies chest pain. endorses dyspnea on exertion. Breast - Denies any lumps and discharges. Heart/Blood vessels - Denies any chest pain Peripheral Vascular - Denies Gastrointestinal - Denies any issue related to vomiting, diarrhea or weight loss or loss of appetite. Genitourinary - WNL Musculoskeletal - complaint of myalgia Sexual - currently not sexually active Endocrine - WNL Neurologic - WNL Psychiatric/mental health - denies any history of depression, anxiety and any behavioral disturbances.

OBJECTIVE:

Vital signs: BP:120/81 Pulse: 108 RR:16 Temp: 101 F (oral) SpO2: 98% Weight 185 Height: 72 BMI: 25.1

General: No acute distress, dry cough.

ASSESSMENT:

General - Alert, oriented and cooperative Skin, hair, nails - pink, warm, dry and intact HEENT- WNL - Normal head shape, normal conjunctiva, exudate pharyngitis, no palatal petechiae. Neck - tender anterior cervical lymph nodes, full range of motion Lymphatic - Tender anterior cervical adenopathy, no posterior nodes palpable and no lymphadenopathy. Chest/Lungs: Bibasilar pulmonary crackles, tachypnea, hypoxia Heart: sinus Tachycardia with a heart of 108 Abdomen: soft, non-tender and no hepatosplenomegaly

Report generated on 1/16/2025, 12:29:10 AM America/New_York

Extremies - no swelling or deformities and no edema.

Diagnosis: Influenza PCR Negative Covid-19 test

Diagnosis: Influenza and Acute Pharyngitis

PLAN:

Influenza PCR

1. Recommend patient get enough sleep and increase fluid intake to prevent dehydration 2. Medications ordered as follows: oseltamivir 75 mg PO twice daily for 5 days, no refills; amoxicillin-clavulantae 875 mg PO twice daily for 5 days, no refills; OTC Tylenol 325mg or Ibuprofen 200 mg 1-2 tablets PO every 4 to 6 hours PRN for myalgia, headache, right ear pain, sore throat and fever. 3. follow up with the clinic in 2 weeks time if symptoms persist 4. recommend patient stay up to date on his immunizations.

Acute Pharyngitis

1. Take medications as prescribed 2. gargling of warm salt water to soothe throat 3. follow up with the clinic if symptoms gets worse or persist in 2 weeks.

Attempt: 3399533

Electronic Health Record by Esther Serwaa Adjei on case Marvin Webster

History of Present Illness

Category Data entered by Esther Serwaa Adjei

Reason for Encounter Fatigue, Dry Cough and Fatigue

History of present illness No annual influenza

Past Medical History

Category Data entered by Esther Serwaa Adjei

Past Medical History Childhood asthma

Hospitalizations / Surgeries Denies any hospitalization

Medications

Category Data entered by Esther Serwaa Adjei

Medications Over the counter Ibuprofen and cough syrup

Allergies

Category Data entered by Esther Serwaa Adjei

Allergies Denies any drug or food allergies

Preventive Health

Category Data entered by Esther Serwaa Adjei

Preventive health No annual influenza

Family History

Category Data entered by Esther Serwaa Adjei

Family History Mother - Hypertension

Social History

Category Data entered by Esther Serwaa Adjei

Social History College Student Occasional social drinker Denies tobacco and illicit drug usage

Report generated on 1/16/2025, 12:29:10 AM America/New_York

Review of Systems

Category Data entered by Esther Serwaa Adjei

General Alert and oriented, does not appear to be in any acute distress and is well- nourished. cooperative during the assessment.

Integumentary / Breast

HEENT / Neck Swollen glands, endorses headache, sore throat

Cardiovascular Endorses right-sided chest wall pain (6-8th intercostal spaces at the midaxillary line), negative for swelling.

Respiratory Positive for dyspnea, dry cough and negative for wheezing

Gastrointestinal Denies any rectal bleeding, blood in stool, constipation, diarrhea, nausea or vomiting.

Genitourinary denies any painful urination or difficulty starting stream

Musculoskeletal Positive for myalgia, negative for back pain, pelvic pain, and urgency

Allergic / Immunologic Denies any food or drug allergies

Endocrine Denies polydipsia, polyuria

Hematologic / Lymphatic Tender anterior cervical adenopathy, no posterior nodes palpable, no other regional lymphadenopathy

Neurologic Negative for seizures, facial asymmetry and speech difficulty

Psychiatric Denies any confusion, dysphoric mood, and sleep disturbances. The patient does not appear to be nervous/anxious and is not hyperactive

Physical Exams

Category Data entered by Esther Serwaa Adjei

General Alert and oriented, does not appear to be in any acute distress and is well- nourished. cooperative during the assessment.

Skin No diaphoresis

HEENT / Neck Head: Bilateral cervical Lymphadenopathy 0.8-1cm eye: conjunctiva pink with no discharge. Anicteric sclera. No edema, redness, or tenderness.

Cardiovascular BP: left 122/82 Right: 120/81: Regular heart rhythm. No murmurs, gallops or bruits

Chest / Respiratory Denies any chest pain. RR: 16 bpm, normal strength. SpO2: 98% clear breath sounds

Abdomen Active bowel sounds

Genitourinary / Rectal Denies any abnormal discharge or difficulty starting stream

Musculoskeletal / Osteopathic Structural Examination

Not assessed

Neurologic Negative Brudzinski and Kernig's sign

Psychiatric Denies any thought of hurting self or others.

Lymphatic Tender anterior cervical adenopathy, no posterior nodes palpable, no other regional lymphadenopathy

Attempt: 3399533