I-Human Week 7 Case Study: Performance Overview For Carmen Walton On Case Camila Baker

I-HUMAN WEEK 7 CASE STUDY: Performance Overview for Carmen Walton on case Camila Baker Thefollowingtablesummarizesyourperformanceoneachsectionofthecase,whetheryoucompletedthatsectionornot.Timespent:3hr15min2secStatus:SubmittedCaseSectionStatusYo u rScoreTimespentPerformanceDetailsTo t a lScore83%HistoryDone82%28min59sec60questionsasked,22correct,5missedrelativetothecase'slistPhysicalexamsDone80%18min14sec31examsperformed,9correct,1partiallycorrect,2missedrelativetothecase'slistKeyQindingsorganizationDone3min1sec23Qindingslisted;11listedbythecaseProblemstatementDone12min10sec96wordslong;thecase'swas98wordsDifferentialsDone60%5min59sec5itemsintheDDx,3correct,2missedrelativetothecase'slistDifferentialsrankingDone100%(lead/altscore)40%(mustnotmissscore)5min1secTestsDone100%13min32sec9testsordered,7correct,0missedrelativetothecase'slistDiagnosisDone100%10secManagementplanDone43min37sec272wordslong;thecase'swas536wordsExercisesDone56%(ofscoreditemsonly)34min18sec5of9correct(ofscoreditemsonly)HistoryNotecardbyCarmenWa l to noncaseCamilaBakerUsethisworksheettoorganizeyourthoughtsbeforedevelopingadifferentialdiagnosislist.1.Indicatekeysymptoms(Sx)youhaveidentiQiedfromthehistory.Startwiththepatient'sreason(s)fortheencounterandaddadditionalsymptomsobtainedfromfurtherquestioning.2.Characterizetheattributesofeachsymptomusing"OLDCARTS".Capturethedetailsintheappropriatecolumnandrow.3.ReviewyourQindingsandconsiderpossiblediagnosesthatmaycorrelatewiththesesymptoms.(Remembertoconsiderthepatient'sageandriskfactors.)Useyourideastohelpguideyourphysicalexaminationinthenextsectionofthecase.HPISx=Sx=Sx=Sx=Sx=Sx=OnsetLocationDurationCharacteristicsAggravatingRelievingTiming/TreatmentsSeverityProblemStatementbyCarmenWa l to noncaseCamilaBakerCamilaBakerisa76yroldfemalewithPMHofHTN,CKD,PUDwithGIbleedduetoNSAIDuse.Shepresentstodaywithbilateralkneepain.Statedthepainstartedabout5yearsago,overthepast2yearshasgottenprogressivelyworse.Ratesthepain4-5,withexacerbationsupto7-8on0-10scale.Painworsenswithwalking,exercisingandstairclimbing.SheistakingTylenol3000gmdailyforpainwhichisnolongereffective,alsostatedcoldweatherincreasespain.Deniesinjuryandfall.associatedsymptomsincludeswollenandpainfulQingerjoints.ManagementPlanbyCarmenWa l to noncaseCamilaBakerANACBCESRLtandRtkneeX-raySynovialQluidanalysisuricacid,serumDiclofenac1%To p i c a l ;apply4gQIDforpain/checkcreatininelevelpriortostarting(Hollier,2021).Inra-articularcorticosteroidinjectionforexacerbation-limitedto4timesperyeararerecommendedforkneeshoulderandhipsandconditionallyrecommendedforhandOA(Hollier,2021)StoptakingTylenol-theuseofacetaminophenasaQirstlineagentforOAisnolongerrecommendedduetosafetyconcernsandlackofefQicacyformusculoskeletalpain(Hollier,2021)Refertoweightmanagement-weightlosscanleadtoimprovementofsymptomsforpatientswithOA(Hollier,2021).RefertoPTforstrengthening--organizedprogramofsupervisedexercisestronglyrecommended,toincludebalanceandstrengthtraining,OAisachronicdisorderrequiringmusclestrengtheningtoprovidejointsupport(Hollier,2021).wearkneebracesforstabilizingthejointwhenexercising.non-pharmacologicalmanagementforOAperHollier,2021.Applyheatand/orcoldasneededforcomfort(on20min/off20min.)isalsoanon-pharmacologicalmanagementinterventionforOAperHollier,2021.Emphasismustbeonnon-pharmacologicaltreatmentstodelayuseofmedicationsthathaveadverseeffects.CamilahasahistoryofGIbleedandshouldnotbetakingNSAIDSwhichistheQirstlinepharmacologicaltreatmentforOA.Ta ichi,acupunctureandyogaarealternativetherapiesthatmaybeconsideredformanagementofsymptoms(Hollier,2021).Followupinonemonth,soonerifsymptomschangeorworsenFurtherfollowupalsoneededforuncontrolledbloodpressure.References:Hollier,A.(2021).Clinicalguidelinesinprimarycare.4thedition.p640-641.ElectronicHealthRecordbyCarmenWa l to noncaseCamilaBakerHistoryofPresentIllnessPastMedicalHistoryMedicationsAllergiesPreventiveHealthFamilyHistorySocialHistoryCategoryDataenteredbyCarmenWa l to nReasonforEncounterHistoryofpresentillnessCategoryDataenteredbyCarmenWa l to nPastMedicalHistoryHospitalizations/SurgeriesCategoryDataenteredbyCarmenWa l to nMedicationsCategoryDataenteredbyCarmenWa l to nAllergiesCategoryDataenteredbyCarmenWa l to nPreventivehealthCategoryDataenteredbyCarmenWa l to nFamilyHistoryCategoryDataenteredbyCarmenWa l to nSocialHistoryReviewofSystemsPhysicalExamsCategoryDataenteredbyCarmenWa l to nGeneralIntegumentary/BreastHEENT/NeckCardiovascularRespiratoryGastrointestinalGenitourinaryMusculoskeletalAllergic/ImmunologicEndocrineHematologic/LymphaticNeurologicPsychiatricCategoryDataenteredbyCarmenWa l to nGeneralSkinHEENT/NeckCardiovascularChest/RespiratoryAbdomenGenitourinary/RectalMusculoskeletal/OsteopathicStructuralExaminationNeurologicPsychiatricLymphatic