NR 509 Week 5 iHuman Case Jose Gonzalez
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$25.00
| Institution | Chamberlain |
| Contributor |
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
Mr. J.G is a 42 year male, generally healthy, without known medical hx, presents with frequent diarrhea, associated with generalized fatigue, mouth dryness, headache and abdominal pain localized in the epigastric region ,4/10 pain scale x 3 days. He recently returned from Chicago when the symptoms started. He uses otc kaopectate to relive his symptoms but it did not help. Objective finding reveal elevated temp 38.6 , hr 102, ortho hypotension 94/50, spleen is palpated during inspiration with diffuse tenderness, without guarding behavior or rebound tenderness. Patient has a positive guard stool but with normoactive bowel sounds without palpable mass.
Management Plan on case Jose Gonzalez
- Pharmacologic Care:
- Supportive Care
- Rest
- Patient Education:
- PROPER HAND WASHING
- Follow Up:
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 | |
