Description

Performance Overview on case Gloria Jenkins

 The following table summarizes your performance on each section of the case, whether you completed that section or not. Time spent: 9hr 21min 51sec

 History Notecard on case Gloria Jenkins

 Use this worksheet to organize your thoughts before developing a differential diagnosis list.

 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.

• Characterize the attributes of each symptom using “OLDCARTS”. Capture the details in the appropriate column and row.
• Review your findings and consider possible diagnoses that may correlate with these symptoms. Use your ideas to help guide your physical examination in the next section of the case.

 Problem Statement for case Gloria Jenkins

G.J. is a 65-year-old Caucasian female who presents …. acute low back pain starting two days ago after moving heavy tables at work. Pain is 7/10, radiating to right buttock and right leg. Describes pain as sharp and continuous, aggravated by moving, not …. though the patient has not tried …. for pain. Denies falls or trauma to affected areas. Denies bowel/bladder dysfunction and numbness or tingling. Physical exam revealed RLE motor …. deficit, hyporeflexia of right patella tendon, and positive straight leg test and contralateral straight leg tests. History of osteoporosis, hypertension, TAHBSO, asthma with prolonged steroid use, and 40-year tobacco use.

Management Plan for case Gloria Jenkins

• Primary Diagnosis
• Additional Ancillary Tests
• Pharmacological Intervention
• Supportive care
• Referrals and follow-up 5 pts (pharmacologic and supportive care, disposition)
• Problem Statement
• Hx card-COMPLETED
• Health Education and Promotion

Electronic Health Record for case Gloria Jenkins

• History of Present Illness
• Past Medical History
• Medications
• Allergies
• Preventive Health
• Family History
• Social History
• Review of Systems
• Physical Exams