NR 576 Week 6 iHuman Virtual Patient Encounter Attempt 3369439 - Molly Howard

History Notecard by Colleen Dunn on case Molly Howard 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 = SxSx = = Onset right flank nausea appetite fever pain Location under ribs Duration 2 days 2 days 2 day 1 day Characteristics started started started 100.2 after after after breakfast breakfast breakfast Aggravating eating occurs occurs after after eating or eating or when when drinking drinking OJ OJ Relieving none none none tylenol Timing toast, toast, toast, tylenol- / apple apple apple helps Treatments juice juice juice temp not gigner gigner gigner ale, anything ale, water, ale, water, else Problem Statement by Colleen Dunn on case Molly Howard The patient is a 33-year-old female with new onset fever/chills 100.2, n/v for 2 days, right flank pain for 2 days, dysuria for 2 days, increased urinary frequency, missed OCP, history of chlamydia, mild suprapubic tenderness with CVA tenderness, history of UTI's-3 in the last year. NKDA. Patient describes the pain as constant and an 8 on 1/10 pain scale, Tylenol ineffective. Negative Murphy and Rovsing's. No hepatosplenomegaly. No hematuria reported. No hematemesis. Normal bm's. Decreased appetite. Attempt: 3369439 Report generated on 12/5/2024, 7:37:04 PM America/New_York Electronic Health Record by Colleen Dunn on case Molly Howard History of Present Illness Category Data entered by Colleen Dunn Reason for Encounter Right flank pain, nausea, vomiting, appetite off History of present illness Flank pain started approximately 3 days ago. Increased urinary frequency, burning, decreased appetite, n/v, fever, flank pain. History of UTI-3 in last year. Last one 2 months ago. Fever today. Past Medical History Category Data entered by Colleen Dunn Past Medical History PMH of UTI x 3 in last two years-nitrofurantoin, hx of chlamydia in college Hospitalizations / Surgeries None Medications Category Data entered by Colleen Dunn Medications ortho tricyclene 28-missed a few pills Allergies Category Data entered by Colleen Dunn Allergies NKDA Preventive Health Category Data entered by Colleen Dunn Preventive health Uncertain of last physical, thinks vaccinations up to date, dentist twice a year Family History Category Data entered by Colleen Dunn Family History Father diabetes 56, mother ok Physical Exams Category Data entered by Colleen Dunn General MH 33 yo female, AO x 4 in NAD, febrile 100.2 Skin no rashes, lesions, or bruises noted HEENT / Neck Head: normocephalic, atraumatic Eyes: PERRLA, no discharge, sclera white, conjunctiva pink Ears: no erythema noted to bilateral ears, bilateral tympanic membranes intact, pearly gray, no