Download Ava Cruz 20 yr old i-Human Case study CC: and more Exams Nursing in PDF only on Docsity! QUESTIONS AND ANSWERS Case Ava Cruz 20 yr old i-Human Case study CC: Headache Assessment Quest and Physical assessment{ INCLUSIVE OF THE PROBLEM STATEMENT,DIAGNOSIS AND TEST RESULTS) TESTED AND CONFIRMED A+ ANSWERS a Ava Cruz: Silas Njane, Attending : Learning Mode
Case Instructions eS
STUDENT CASE PLAY INSTRUCTIONS
Sn
Below is the breakdown of the grading rubric for this Basic DDx case. You will be allowed to push the Hx Hints Button and receive feedback on
your history questions 5 times per case
Your history question limit for your patient is 90 questions, please use them wisely,
Ava Cruz
20 yio
§! 6" (168 cm)
115.0 Ib (52.3 kg),
a) HPI statement (10% of grade)
b) Plan covering all critical components of patient's final diagnosis (40%)
Reason for encounter
Headache y
> ¢) Overall i- Human percentage (50%)
The software platform is designed to help you become proficient in the diagnostic reasoning process (the steps prior to the final diagnosis), so
you can apply this process in the real clinic setting. Key to minimizing medical errors is the clinical consideration of a broad differential diagnosis
list and the selection of tests to either "rule in’ or “rule out" these diagnoses
Detailed Instructions Below.
NOTE FROM YOUR INSTRUCTOR: You are required to complete all sections of the EHR This section
in be found by clicking on the
Case authored by: Kathieen Wittels, MD
ve ] PSS
Test Results Diagn
previously? others, it's just that | keep on having
them.
Characteristics Does your headache come and go? | Don't all headaches come and go.
Has there been any change in your | I'm getting them more often | guess.
eis headache over time? They last longer and seem worse.
Do any foods seem to bring the
@ | Characteristics headaches on? Not that I've noticed.
Is there any pattern to when your
e Characteristics headaches occur? Yeah, no...not really.
It's Kind of dull, like a bad pressure.
e Characteristics es she: pain In Your head Kind of like if there were a tight
Circle or cap around my head
Does anything make your ’
e Aggravating headache better or worse? No, | don't think so.
Relieving |
Do you have any awareness or in ||
@ =| Timing/Treatments | warning symptoms that occur Pongmmes yes, somenmes: no. Its
before the headache begins?
Oh, you know, I've seen doctors
before. | take acetaminophen or
What treatments have you had for 7
e Timing/Treatments your headache? ibuprofen or both. | haven't taken
1
eo Timing/Treatments
x Timing/Treatments
@ | Severity
How often do you have headaches
like this?
Do your headaches occur when
your Caffeine intake changes?
How severe (1-10 scale) is your
headache?
Can you describe how you fell?
anything today. | wanted to be
checked out without it.
Maybe, like, about 3 times a week? |
| don't drink much in the way of
coffee or caffeine drinks.
| don't know... that's hard to say.
My boyfriend was saying something ¢
and | was not paying attention
(looks away), he got angry and
pushed me down (sob), | hurt my
wrist and had an x-ray taken last | |
week. | am relieved that | did not
have a fracture.
E13 XS T utah
Test Results Diag
PMH, FH, SH as Needed
@ Asked X Not asked
r ln
Information Obtained
Graded Approach Question Response Clinic Notes
Can you tell me about any current Se i chain eeacnt Gd get
e PMH pc past medical problems you have | 7 Oring ago. There might be
something about that in my chart.
Has your partner ever threatened to |
oot harm or kill you? | Not
| You know, | do not have a job. Cut-
backs, they said. Since | lost my job
my boyfriend is not making me 5
| share the rent. | mean he isn't
| making me or anything, but...well
| you know...(looks away). | have not
| Does your partner or the been able to share the financial
x SH | relationship have financial burden and | am dependent on him.
difficulties? Sometimes it really gets to him. (in
a quiet voice) Last time | spent too
much money on groceries he got | |
really upset. (looks away)
Well....like...well...He grabbed my |
arm a few weeks ago. (looks away) |
it's hard
I guess so, I have all sorts of | |
Is the violence or controlling problems when he gels angry, He
e SH behavior becoming worse or more proved meine Chest Dutne
| frequent? wasn't trying to hurt me. You know |
| how guys are...it really was my |
fault |
He Is not jealous, but he expects
x |sH Is your partner jealous toward you = me to pay full attention whenhe 4
Of controlling of you? says something. He sometimes | |
4 loses his temper (looks away) | |
Are you experiencing any violence, No, not at all. Why would you ask |
@ SH "abuse, trauma, or bullying? If so, by that? (looks away). He justgelsa_ | . |
whom? little angry sometimes. | i. :
Test Results
Diagnc
He is not jealous, but he expects
x |sH Is your partner jealous toward you | me to pay full attention when he | i
or controlling of you? says something. He sometimes ;
loses his temper (looks away).
Are you experiencing any violence, | No, not at all. Why would you ask
@ (SH abuse, trauma, or bullying? If so, by | that? (looks away). He just gets a
whom? litle angry sometimes.
Has anyone suffered from |
e FH migraines in your family? | Not that | know of.
Review of Systems (ROS)
Select the major body systems that have not been touched on during the interview process for the HPI.
@ Asked X Not asked ?
Graded | Question Response Information Obtained Clinic
| Notes
| Have you noticed any bruising,
@ | bleeding gums, nose bleeds, or other | No
| sites of increased bleeding?
Do you have problems with heat or cold
@ | intolerance, increased thirst, increased |), no
sweating, frequent urination, or change :
in appetite?
Do you have problems with dizziness,
fainting, spinning room, seizures,
e@ weakness, numbness, tingling, or No, I haven't passed out or felt dizzy.
tremor?
Do you have any problems with
nervousness, depression, lack of Hearing voices?!7! No way. Things |
@ | interest, sadness, memory loss. or aren't perfect though. But | guess they
mood changes, or ever hear voices or _ aren't for lots of people. (looks away) t
| see things that you know are not there? | fs
aT s }
| Do you have any problems with fatigue. f
e@ difficulty sleeping, unintentional weight Uh, no U
| loss or gain, fevers, or night sweats? }
Do you have any problems with |
| headaches that don't go away with
nieumeielnmenlinn
EHR
Test Results Diag
Postal
Ms. Cruz has bruising on her left breast, as well as her upper left arm. These bruises appear to be in different
Stages of healing. Note, however, that determining the age of a bruise can be quite inexact. Dark coloration is not
limited to fresh bruising; it may be present at any stage.
e Hematologic considerations:
= Signs suggestive of a platelet disorder include easy bruising, petechiae, and purpura.
+ Easy bleeding, suggestive of a coagulopathy, is manifested by organ- or location-specific signs; e.g., epistaxis,
menorthagia.
+ inspecUpalpate head
When evaluating a patient who presents with a headache, it is important to look for signs of trauma:
e Skull hematomas
° Bony depression
© Battle's sign
© Raccoon eyes :
e Hemotympanum j
palpate extremities I
Itis important to assess for underlying traumatic bone or ligament injuries, given the bruising found on this patient's left ‘
arm and breast.
* palpate neck
Assessment for signs of meningismus or nuchal rigidity in a patient who presents to the ED with headache symptoms is
a crucial first step in evaluating for the presence of meningitis or subarachnoid hemorrhage
* perform fundoscopic exam with ophthalmoscope
Examination of the eyes is cntical to assessment for signs of elevated intracranial pressure; e.g., unequal pupils or
papilledema.
+ pulse
respiration
= sensory tests (light touch, pain, position, temperature, vibration)
The neurologic exam Is critical to the assessment of headache symptoms. Evaluation of mental status and identification
of any deficits may help localize the source of the headache to a particular area of the brain, as in the case of a tumor.
* Spo:
* temperature
* visual inspection extremities
itis important to assess for underiving traumatic hone arliqament iniuiries_qiven the brilsina foundan this natient’s left
ATMEL) Proceed
Copyrant © 2015-2023 Human Patents. a part of Kalan. inc. All rohts reserved.
ical Exa ] SIUC Test Results Diagn
* Spo:
+ temperature
_ + Visual inspection extremities
ILls Important to assess for underlying traumatic bone or ligament injuries, given the bruising found on this patient's left
arm and breast.
® Not Required, Not Inappropriate
* auscultate lungs
© You performed the simulation correctly.
You interpreted left lung and right lung correctly.
* cognitive status
* height
+ weight
X Missed
* breast exam
Having identified a bruise on the patient's left arm, it is important to perform a complete skin exam to look for other
bruising. Bruising can be a result of trauma or a hematologic disorder.
Ms. Cruz has bruising on her left breast, as well as her upper left arm. These bruises appear to be in different
Stages of healing Note, however, that determining the age of a bruise can be quite inexact. Dark coloration is not
limited to fresh bruising; it may be present at any stage
© Hematologic considerations
= Signs suggestive of a platelet disorder include easy bruising, petechiae, and purpura.
= Easy bleeding, suggestive of a coagulopathy, is manifested by organ- or location-specific signs; €.g., epistaxis,
menorthagia.
* perform ocular motor test
© YOU did not cover all the areas “
© Your interpretation was correct
-
* point-to-point test arms (fingers-to-nose)
The neurologic exam Is critical to the assessment of headache symptoms. Evaluation of mental status and identification
of any deficits may help localize the source of the headache to a particular area of the brain, as in the case of a tumor.!
ical Exam PTS Test Results Dizon
® Not Required, Not Inappropriate '
auscullate lungs
© You performed the simulation correctly.
You interpreted left lung and right lung correctly.
= cognitive status
= height
= weight
X Missed
+ breast exam 2
Having identified a bruise on the patient's left arm, it is important to perform a complete skin exam to look for other
bruising. Bruising can be a result of trauma or a hematologic disorder.
© Ms. Cruz has bruising on her left breast, as well as her upper left arm. These bruises appear to be in different
stages of healing. Note, however, that determining the age of a bruise can be quite inexact. Dark coloration is not r
limited to fresh bruising; it may be present at any stage.
e Hematologic considerations:
= Signs suggestive of a platelet disorder include easy bruising, petechiae, and purpura.
» Easy bleeding, suggestive of a coagulopathy, is manifested by organ- or location-specific signs; €.g., epistaxis,
menorthagia
* perform ocular motor test
© You did not cover all the areas.
e Your interpretation was correct
* point-to-point test arms (fingers-to-nose)
The neurologic exam Is critical to the assessment of headache symptoms. Evaluation of mental status and identification
of any deficits may help localize the source of the headache to a particular area of the brain, as In the case of a tumor.
* reflexes - deep tendon a
The neurologic exam Is critical to the assessment of headache symptoms. Identification of any deficits may help localize
the source of the headache to a particular area of the brain, as in the case of a tumor.
You did not perform any simulation.