Tim

Name: Tim Davis

Age: 42 yrs. Male

Allergy: NKDA

Height:71

Temp: 38.6 (101.5F) oral

PULSE: 102 bpm regular rhythm strength normal

B/P: 114/62 left, 114/62 right, normotensive, Pulse pressure: normal

Orthostatic B/P: 94/50mmg upon standing

Resp: 14 bpm rhythm, effort unlabored

Spo2: 94%

Weight: 82.7kg (180.0 lbs.)

BMI: 25.1

Cog Status: A and O X 4

HEENT/NECK: Good dentition thyroid within normal limit for size and size and consistency, no cervical lymphadenopathy or mass.

Cardiovascular: regular rhythm and rate no murmur or gallop, no peripheral edema

Chest/ respiration: thorax normal to percussion, breath sound equal / clear bilaterally

Abdomen: non distended, no hepatosplenomegaly, mass or herniation, soft, non-tender throughout

Neurologic: reflexes 2 +bilaterally throughout CN ll-Xll intact

Musculoskeletal: normal muscle tone and bulk bilaterally

Genitourinary: normal muscle tone and bulk bilaterally

Genitourinary/rectal: normal circumcised prostate normal

Immunologic: normal

Skin: no pallor jaundice, ecchymoses, or rash, no gynecomastia

Lymphatic: no adenopathy

Hematologic: no ecchymosis, no petechiae

History mgt / plan: lipid panel done

Result:

Cholesterol: 239mg/dL (low risk <200, moderate 200-239, high risk >239)

HDL: 52unit dL ( maj risk < 40, Neg risk > 59)

LDL:152unit/L (Low risk < 130, moderate 130-159, high risk >159)

Triglyceride: 175mg/dL (35-135, high risk 40-160)

Follow up: Called Mr. Davis with result

Cholesterol borderline elevation

Cholesterol lowering diet recommended.

Chief complain/complain: Terrible watery diarrhea that start 3 days ago and he just feel wipe out, he went every 2hours, headache and mouth feel like someone stuck bunch of cotton in it.

Skin: Warm and mildly diaphoretic

Pain: A bit all over the head

Diarrhea: Most distressing start 3 days ago., 8 times per day tried some meds but no work

Hematuria: Streak of blood in the stool last time an hour ago, stomach feel sore and painful

Diarrhea: Nothing makes it better or worse, haven’t slept much at all in 36 hours

Headache: Same time as diarrhea but not sure, inside /deep headache

Nausea and vomiting: Not throw up at all

Abdomen: Stomach feel sore and crampy comes and go

Preventative health: Biannual dental cleaning with annual dental exam

Immunization: Up to date including seasonal flu

Past medical history: childhood illness: chicken pox, adult illness : none, multiple bouts of diarrhea of unclear etiology with no studies done.

Family history: Father 68 healthy except for mild hypertension controlled by medication, mother 67 healthy with no current medication, children 8yrs and 12 both healthy

Social history: Partner in direct marketing company that publisher variety of health-related magazine, married with 2 children live in a house in Westchester, no pet, never smoke, for alcohol take 1 glass of wine 3 to 4 night weekly, sexual history: 4 sexual partner all women prior to meeting his wife at age 26, monogamous since then

QUESTIONS

I. 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:

i. diagnostic tests

ii. medications: write a specific prescription for each medication, including over-the-counter medications

iii. suggested consults/referrals

iv. client education

v. follow-up, including time interval and specific symptomatology to prompt a sooner return

vi. cite at least one relevant scholarly source as defined by  program expectationsLinks to an external site.

vii. Click "Submit" once the case is complete. Use this guide to  download the Performance Overview Report Links to an external site. .

II. Reflection: Address the following question: Some clinicians may find it difficult to explain the logic behind their clinical thinking. As you gain experience, your clinical reasoning will begin at the outset of the patient encounter, not at the end. Reflect on the clinical reasoning you used during this virtual patient encounter. Describe the steps taken to identify and interpret the key findings in this case.  What are some “lessons learned” within the assessment that you can apply to your professional practice as a provider? Include the following components:

i. write 150-300 words in a Microsoft Word document

ii. demonstrate clinical judgment appropriate to the virtual patient scenario

iii. cite at least one relevant scholarly source as defined by program expectations

iv. communicate with minimal errors in English grammar, spelling, syntax, and punctuation