Assignment Prompt & Instructions
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:**
1. Identifying information/chief complaint
2. History of present illness
3. Other active medical problems, medications, habits, and allergies
4. Physical Examination- key findings
5. Labs
6. Physical examination (key findings only)
**Identifying information/chief complaint: 20 points**
**Content – contains 4 elements, expressed in a single sentence**
1. The patient’s age and sex
2. 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
3. The patient’s reason for presentation
4. The duration of symptoms
**H** _**istory of Present Illness**_: **20 points**
The fundamental part of the oral presentation and the source of 90% of correct diagnoses.
**Content**
1. All “positive” elements (i.e., what occurred) precede all “negative” elements (what was absent)
2. “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?
3. Current symptoms and treatment?
4. Are any complications present?
5. 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)**
1. Brief summary (using key words, see previous) of other active medical problems mentioned in your identifying information sentence but not discussed in HPI.
2. Social history- smoking, alcohol, drug, and/or vaping/e-cigarette use
3. Medications – give dosages
**Physical examination**
1. Begin with “general description and vital signs”
2. Include all abnormal findings
3. Among normal findings, include only those essential to the understanding of the chief Complaint
_**Laboratory )**_
1. Include all abnormal labs, with comparison to previous value
2. Among normal labs, includes only those relevant to the chief complaint
3. Any labs presented should appear in traditional order (electrolytes/creatinine/glucose,complete blood count, other chemistries, urinalysis, vaginal culture, transvaginal ultrasound
_**Assessment & Plan**_
1. 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”).
2. Ask yourself “At the moment I am presenting the case, what is the principal unresolved issue”
1. 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)
2. 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
3. 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
4. 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).
– 2 years ago