NR 511 Week 5 iHuman Virtual Patient Encounter Attempt 3748568 - Dorothy Jones

History Notecard by Kimberley Alvey on case Dorothy Jones 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: 3748568 Report generated on 11/30/2025, 4:46:32 PM America/Denver Management Plan by Kimberley Alvey on case Dorothy Jones DIAGNOSITIC TESTS- CBC, CMP, AMYLASE, LIPASE, CRP, LACTIC, UA, HEMOCULT, CT-ABDOMEN/PELVIS WITH CONTRAST (Chalasan,2024) PHARMACOLOGIC: for nausea, Ondansetron IV 4mg, repeat every 8 hours as needed for nausea or vomiting Dilaudid 0.5mg IV every 4 hours as needed for abdominal pain 7-10 *Start Normal Saline 2 liter IV bolus, then 125ml/hr (Chalasan,2024) CONSULTS: General Surgery for evaluation, Gastroenterology for evaluation (Chalasan,2024) SUPPORTIVE-NPO place 2 IVs Nasogastric tube placement, place to low intermittent suction. intake and output every 4 hours Bedrest with bedside commode(Chalasan,2024) EDUCATION-educate the patient on pending plans, results of labs and radiology results, inform the patient of pending consults and the reason behind them. (Chalasan,2024) FOLLOW-UP --report any fever or chills, increased abdominal pain, worsening vomiting, uncontrolled nausea, or lightheadedness (Chalasan,2024) REFERENCES: Chalasani, P., Ilyas, H., El-Jurdi, K., & Kam, M. (2024). S4772 Unanticipated Complication: Bowel Preparation Resulting in Small Bowel Obstruction - A Case Report. The American Journal of Gastroenterology, 119(10S), S3015– S3016. https://doi.org/10.14309/01.ajg.0001048456.37357.51 Attempt: 3748568 Report generated on 11/30/2025, 4:46:32 PM America/Denver Family History Category Data entered by Kimberley Alvey Family History Mother-84-hypertension, high cholesterol and fibroids Father-85-hypertension Daughter-24- no health problems to report Grandparents-80-90's year old-passed-unsure about health problems Social History Category Data entered by Kimberley Alvey Social History works as a financial analyst for a tech company lives with significant other social drinker-3-4 12 ounce beer daily Review of Systems Category Data entered by Kimberley Alvey General denies any fever, weight loss, weight gain and poor appetite Integumentary / Breast denies any rashes, itching, or changes in skin color. BREASTS-defered HEENT / Neck denies any trauma or tenderness, denies any changes in vision, eye redenss or drainage, denies any pain or drainage from ears, denies any congestion, rinorrhea or sinus pain, denies any sore throat or hoarseness. denies any swollen neck glands, denies any stiffness, pain or limited ROM Cardiovascular denies any chest pain, palpatations, racing heart and leg swelling. Respiratory denies any cough, shortness of breath and wheezing Gastrointestinal reports nausea, vomiting-green bile, abdominal pain-mid abdomen umbilical area, watery diarrhea 2 days ago, constipation since then Genitourinary denies any burning, discharge or pain Musculoskeletal denies any