17 Feb Please use this scenario below to answer the questions and create a history, physical, assessment and plan/treatment. Please feel free to make up patien
Please use this scenario below to answer the questions and create a history, physical, assessment and plan/treatment. Please feel free to make up patient information to match story line an treatment plan.
May use references as needed app format
A 16-year-old girl presents for a preparticipation physical. A review of systems reveals that her menstrual cycles have been irregular since she started training for the cross-country season. She admits to being a picky eater but denies restricting food intake, binge eating, or self-induced vomiting. She has no significant medical history. She is not on any medications. Her body mass index is 18.5 kg/m2. A urine pregnancy test in the office is negative. For which of the following is she at greatest risk?
- Basic structure:
- Identifying information/chief complaint
- History of present illness
- Other active medical problems, medications, habits, and allergies
- Physical Examination- key findings
- Labs
- Physical examination (key findings only)
Identifying information/chief complaint: 20 points
Content – contains 4 elements, expressed in a single sentence
- The patient’s age and sex
- The patient’s active ongoing medical problems, mentioned by name only, and including only the most important, i.e., no more than 3 or 4
- The patient’s reason for presentation
- The duration of symptoms
History of Present Illness: 20 points
The fundamental part of the oral presentation and the source of 90% of correct diagnoses.
Content
- All “positive” elements (i.e., what occurred) precede all “negative” elements (what was absent)
- “Positive” statements a. Are presented in chronologic order b. Are attentive to detail b c. If the current problem is a direct extension of a previous ongoing active medical problem, the HPI begins with a 1-2 sentence summary of that ongoing medical problem, using “key words”: 1. Date of diagnosis? 2. How was diagnosis made?
- Current symptoms and treatment?
- Are any complications present?
- Are any objective measures of the chronic problem available? (e.g., a1c for diabetes)
Other active medical problems, medications, social history, and allergies: (10 points)
- Brief summary (using key words, see previous) of other active medical problems mentioned in your identifying information sentence but not discussed in HPI.
- Social history- smoking, alcohol, drug, and/or vaping/e-cigarette use
- Medications – give dosages
Physical examination
- Begin with “general description and vital signs”
- Include all abnormal findings
- Among normal findings, include only those essential to the understanding of the chief Complaint
Laboratory )
- Include all abnormal labs, with comparison to previous value
- Among normal labs, includes only those relevant to the chief complaint
- Any labs presented should appear in traditional order (electrolytes/creatinine/glucose,complete blood count, other chemistries, urinalysis, vaginal culture, transvaginal ultrasound
Assessment & Plan
- Begin with a positive statement of the patient’s problem, which is either a (1) symptom, (2) sign, (3) abnormal laboratory test, or (4) diagnosis. Choose the highest number on this list that no one could argue with (e.g., if the patient has pelvic pain and a 4 cm simple ovarian cyst, the assessment focuses on the abnormal lab “ 4 cm”).
- Ask yourself “At the moment I am presenting the case, what is the principal unresolved issue”
- If the principal unresolved issue is diagnosis, your assessment focuses on differential diagnosis: (i) list the 3-5 most likely diagnoses, (ii) state which diagnosis is most likely and why, and (iii) state why other diagnostic possibilities are less likely (draw your evidence from the H and P you just presented)
- If the principal unresolved issue is therapy, your assessment should: (i) state the diagnosis or problem, (ii) state which therapy you gave or plan to give, and why you made this decision, (iii) state which complications you might anticipate
- If you are presenting the morning after overnight call, the case presentation usually ends with a 1-2 sentence summary of what happened overnight, after implementation of your initial decisions
- The assessment and plan focus only on those active issues keeping the patient in the hospital (stable outpatient problems are included in your write-up are omitted in the inpatient case presentation).