Case: Problem Statement
This is an 18-year-old male college student with a history of childhood asthma who presents with acute onset of nonproductive cough, sore throat, fatigue, myalgias, and headache × 4 days. He reports a sick contact, and has not had annual flu vaccine or COVID booster. Physical examination reveals a temperature of 101°F, tachycardia, erythematous pharynx, and anterior cervical lymphadenopathy, but is negative for adventitious breath sounds and hepatosplenomegaly.
Case: Management Plan
Pharmacologic Care:
- Acetaminophen OTC 325 mg 1-2 tabs PO q 4-6 hours; maximum dose 10 tablets per day pm fever, headache, myalgias
- Dextromethorphan HBr + guaifenesin 20mg/400 mg 20 mL PO q 4 hrs; maximum dose 6 doses daily pr cough
Supportive Care:
- Increase fluid intake
- Rest – no class attendance – school note provided for 48 hours
- Marvin Webster Jr i-Human Patients Case Study
Patient Education:
- Offered education on the diagnosis and treatments provided
- Educated patient that oseltamivir is not indicated given timeline since symptom onset
Follow-Up/Disposition:
- Follow up in the student health center if not improving within 48 hours or headache worsens or if shortness of breath develops
- At future visit, address vaccination status – encourage flu vaccine and COVID booster
- Marvin Webster Jr i-Human Patients Case Study
Week 2 iHuman Assignment Reflection Worksheet
Your Name
Chamberlain University College of Nursing
Course Number: Course Name
Name of Instructor
Assignment Due Date
Week 2 iHuman Assignment Reflection Worksheet
Please read the assignment guidelines and rubric. Respond substantively to each self-reflection question below. Write on this template.
A. Assess your ability to gather information on your client within the iHuman Virtual Patient Encounter.
1. Use the iHuman score sheet to review your results for the focused health history and focused physical exam. How did you perform?
2. What did you find easy or difficult about navigating through the focused health history and focused physical exam sections of the case?
3. Describe one strategy to improve your performance in the next Virtual Patient Encounter.
B. Assess your performance in documenting your findings on the electronic health record (EHR).
1. What did you find easy or difficult about navigating through the documentation of the history and physical within the system?
2. Did you document all required components in the case?
3. Describe one strategy to improve your performance in the next Virtual Patient Encounter.
C. Assess your performance in determining key findings and reviewing the most significant active problem.
1. What did you find easy or difficult about navigating through the key findings and organization section of the case?
2. How did your key findings compare with the expert’s findings?
3. Describe one strategy to improve your performance in the next Virtual Patient Encounter.
D. Assess your performance in creating and documenting a problem statement within the iHuman case.
1. What did you find easy or difficult about creating the problem statement?
2. How did your problem statement compare with the expert’s response provided?
3. Describe one strategy to improve your performance in the next Virtual Patient Encounter.
E. Assess your performance in creating and documenting a management plan within the iHuman case.
1. What did you find easy or difficult about creating the management plan?
2. How did your management plan compare with the expert’s response provided?
3. Describe one strategy to improve your performance in the next Virtual Patient Encounter.
References
0320 RB/KK
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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
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Week 2: i-Human Practice Case & Reflection
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Week 2: i-Human Practice Case & Reflection |
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Criteria |
Ratings |
Pts |
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This criterion is linked to a Learning OutcomeFocused Health History Complete a focused health history. |
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5 pts |
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This criterion is linked to a Learning OutcomeFocused Physical Exam Complete a focused physical exam. |
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5 pts |
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This criterion is linked to a Learning OutcomeEHR Documentation – Subjective Data Document the history of present illness (HPI) and focused review of systems (ROS) in the EHR. Documentation should be: 1. accurate 2. detailed 3. written using professional terminology 4. pertinent to the chief complaint 5. include subjective findings only |
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5 pts |
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This criterion is linked to a Learning OutcomeEHR Documentation – Objective Data Document physical exam in the EHR. Documentation should be: 1. accurate 2. detailed 3. written using professional terminology 4. pertinent to the chief complaint 5. include objective findings only |
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5 pts |
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This criterion is linked to a Learning OutcomeKey Findings Organize the key findings with the most important findings first and the least important findings last on the list. |
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5 pts |
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This criterion is linked to a Learning OutcomeProblem Statement Document sample problem statement in the EHR 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 |
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5 pts |
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This criterion is linked to a Learning OutcomeManagement Plan Document sample treatment plan within the iHuman Virtual Patient Encounter. 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. Provide rationales for each intervention and cite at least one relevant scholarly source as defined by program expectations |
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