Ihuman case studies help in assessing patients and performing diagnosis. It helps clinicians perform assessments on real life-like patients.
Below is a sample of an ihuman case study for Emma Ryan. It provides a detailed assessment of her condition.
CC: 2 y/o M/F Chief complaint is a short1-2 statement or word phrasefrom patient andshould be listed in “quotes”
Mother’s statement
“2 days ago, she started with a runny nose and cough” | HPI: pertinent s/s;+/- ROS/prior episodes/recent travel/ill contacts Emma Ryan is a 2-year-old girlwho presented to the clinicwith her motherwith a complaint of runny nose and a cough that started 3 days ago and fever that started 2 days ago. She tolerates milk well, but her appetite is reduced with no change in the number of wet diapers. The mother reports she did not receive the flu vaccine this season; she is exposed to secondhand smoking at home and exposure to sickchildren at daycare. Onset: Cough and runny nose started 3 days ago and feverfor the past 2days Location: NA Duration: About 3 days and symptoms have persisted Character: Cough is unproductive Aggravating/alleviating factors: No aggravating or alleviating noticed or reported by mom Related symptoms: Fussiness and reduced appetite. Crying could be an indication of pain of discomfort (FLACCscore of at least 2) Treatments: Tylenol every4 hours for fever Significance: Fever in toddlers is significant and fussiness and loss of appetite isindicative of discomfort |
PMHx child/adult illness/hospitalizations/immunizations
No hospitalizations, trauma, or other injuries Immunizations: Mother states she has not received flu vaccine this season but update on all recommended vaccinations. | SurgHx type/when/why/complications No history of surgery |
FamHx Grandparents (if known)/Parents/siblings/children
Mother-age31-No history of medical problems Father-age 35 with history of mild intermittent asthma Brother-age 5 healthy | SHx Tobacco/vaping/ETOH/illicit drug use/occupational/environmental/relationships Exposed to secondhand smoking by bothparents in thehome |
Reproductive Hx Female: Age of menarche/menstruation cycle duration/gravida para status/Childbirth hx/sexual hx and concerns/LMP/menopause Breast/cervical screening (if any) Male: Sexual hx and concerns/issues with fertility (if any)/Testicular or prostate screening (if applicable) Screening for STI’s (if applicable)
Toddler, no schedule history | Allergies (Food, Drug,Environmental, etc.)
No known allergies
List of Medications/supplements (prescription, OTC, complementary alternative therapies) Tylenol OTC for fever |
Review of Systems: (ROS) Use this column to document the ROS below. General: Crying HEENT: Runny nose Pulmonary: Nonproductive cough CV: No shortness of breath GI: Wears diapers. She has about1-2 stool diapers per day, decreased appetite and no vomiting Decrease in appetite GU: No change in number of wet diapers | From the ROS:list/highlight the currentsymptoms/complaints to generate a list of pertinent “reported or denied” symptoms below: Pertinent Positive ROS: Cough, runny nose,decreased appetite Pertinent Negative ROS: No signs of shortness of breath, No changes in voiding and bowel movement, no vomiting |
MS: No recent trauma or injury Heme: No sign bruising Lymph: No complaint Endocrine: No history of endocrine disorder Derm: No signs of rash Neuro: No history of Seizures Psych: No psychological concerns | |
Physical Exam: (PE)Use this columnto document the PE below. Vitals(HR/BP/RR/T/SpO2/Ht/Wt/BMI%) HR: 85, BP 95/60, RR: 20, SPO2: 98%, Height: 2ft 2 inches, Weight: 27lbs.,BMI: 16.4 General: Crying toddler HEENT: Normocephalic, atraumatic, no deformities, face symmetrical, Pupils normal, reactive, earshave no discharge and appears normal,bilateral tympanic membranes with erythema and severe bulging, nose has no discharge or polyps, pharynxwith erythema and exudates Neck: No visible scars or deformities or lesions Pulm Respirations regularand unlabored, normallung sounds, negative for wheezing. CV: Normal heart sounds, HR 85 GI: No guarding or rebound tenderness. Bowel soundspresent in all 4 quadrants GU: No diaper rash Neuro: Awake and alert Derm: Skin turgornormal. Skin warmand dry withno lesions MSK: Normal bulk and tone | From the PE: list/highlight thepresence or absence of objective findings to generate a list of pertinent “(+) or (-)” symptoms below: Pertinent Positive PE findings: Bilateral tympanic membranes with erythema and severe bulging, pharynx with erythema and exudates
Pertinent Negative PE Findings: Respirations regularand unlabored, normallung sounds, negative for wheezing. |
| Psych: Not assessed | |
Lab/Radiology or otherDiagnostic data:
Rapid influenza diagnostic test (RIDT)
Influenza PCR
| Problem Statement: Emma Ryan is a 2-year-old girlwho presented to the clinicwith her motherwith a complaint of runny nose and a cough that started 3 days ago and fever that started 2 days ago. She tolerates milk well, but her appetite is reduced with no change in the number of wet diapers. Physical examination shows tympanic temperature of 101.1 F, bilateral severe tympanic membrane bulging and erythema as well as pharyngeal exudate. Risks include the lack of flu vaccine this season, exposure to secondhand smoking at home and exposure to sick children at daycare. |
IHUMAN TOTAL CASE SCORES: #1:75% #2: 94% | List the differential diagnoses (Must notMiss/Leading/Alternate/Concluding) *Include ICD 10 codes after each |
| Based on patient’s age/risk factors, what preventive screening would be recommended attoday’s or a future visit: |
Must NotMiss/Leading: |
Grade B Recommendations:
Screening for dental Carries in children frombirth through age 5 | Influenza (J11.1) Must be ruled out because children are at higher risk. Nonspecific fever, cough, no flu vaccine, but negative RIDT and negative influenza PCR rules it out Alternate: |
Skin cancer prevention: Behavioral counselingfor parents of young children | Pharyngitis (J02.9) pharyngeal erythema and exudates, fever, runny nose,cough |
Vision screening in children 6 months to 5 years
(USPSTF, 2021) | Upper respiratory infection (URI) (J06.9) coughing, and fever Otitis media(H66.9) Fever, fussiness, erythema and bulging of bilateral tympanic membrane
Concluding: Otitis media (H66.9)with Upper Respiratory Infection (J06.9): otitismedia often occurs with upper respiratory infections (Pettigrew et al., 2011) which results in edema and blocking of the eustachian tubes causingmiddle ear infection. |
Reflective ThinkingExercises
- History-Taking: Describe your history taking scores and strengths you identified when gathering data.What went well?Also, describe your challenges in gathering data and list areas of your personal needed improvement. Note any missedareas that could be safety issues/errors leading to missed or incorrect diagnosis.
I have improved on history taking compared to previous cases. I still need to be targeted with appropriate questions so that history takingdoes not take all the time. My historytaking scores are stilllow the first attempt was 54% with an improvement with the second attempt. I still need more practice to get more of the associated questions.
- Physical Exam: Describe your physical exam scores and strengths you identified when performing selected exams on your patient. Did you performan excessive amountof exam items? Did you miss any pertinent exam items identified in the case leading to diagnosis? Note any missed areas that could be safety issues/errors leading to missed or incorrect diagnosis.
Physical exam scores are 100% for the first attempt and 94% for the second attempt. I missed documenting by findings of heart auscultation althoughI performed the examination. I need to pay more attention.
- Evidence-based decision making: Discuss the evidence-based resource(s) utilized while seeing the patient. These can be your course readings/IHUMAN lessons/other course info as well as any external articlesor supporting literature to help you gain a better understanding of categorizing possible diagnoses in your case. How did you use the symptoms/patient presentation, plus your exam findings, to formulate a differential diagnosis list? What specific feedback from previous case studieshas your facultyidentified that you plan to incorporate on future cases to avoid pitfalls in data gathering or decision making?What will you do differently to improve?
The required text readings from S2D and Dain was very beneficial especially S2D with identifying differential diagnosis.
References
ICD10Data.com. 2021 ICD-10-CM Codes. https://www.icd10data.com/ICD10CM/Codes.
Johnson, N. (2018) NP H & P. ReNursingEdu LLC. www.ReNursingedu.com
Kaplan, Inc. (2020).Case study: Emma Ryan. IHumanpatients by Kaplan.
Pettigrew, M. M., Gent, J. F., Pyles, R. B., Miller, A. L., Nokso-Koivisto, J., & Chonmaitree, T. (2011). Viral-Bacterial Interactions and RiskofAcute Otitis Media Complicating Upper Respiratory Tract Infection. Journal of Clinical Microbiology, 49(11), 3750–3755. https://doi.org/10.1128/jcm.01186-11
United States PreventiveServices Taskforce (2021). A and B Recommendations: United States Preventive ServicesTaskforce. A and B Recommendations | United States Preventive Services Taskforce. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-and-b-recommendations.
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