Performance Overview on case Jose Gonzalez
The following table summarizes your performance on each section of the case, whether you completed that section or not.
History Notecard on case Jose Gonzalez
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. (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.
Problem Statement on case Jose Gonzalez
This 42-year-old male patient presents with diarrhea for 3 days and associated abdominal pain, blood in stool, mild nausea, chills, dry mouth, headache, and lightheadedness. The physical exam is notable for a fever of 101.5, tachycardia of 104 bpm, orthostatic hypotension, and reduced skin turgor
Management Plan on case Jose Gonzalez
- Diagnostic Tests:
- Pharmacologic Care:
- Patient Education:
- Follow Up:
- References:
Electronic Health Record on case Jose Gonzalez
- History of Present Illness
- Past Medical History
- Medications
- Allergies
- Preventive Health
- Family History
- Social History
- Review of Systems
- Physical Exams
Instituition / Term | |
Term | Uploaded 2023 |
Institution | Chamberlain |
Contributor |