Performance Overview on Case Andrew Chen

The following table summarizes your performance on each section of the case, whether you completed that section or not.

History Notecard on case Andrew Chen

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

1. 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.
2. Characterize the attributes of each symptom using "OLDCARTS". Capture the details in the appropriate column and row.
3. Review your findings and consider possible diagnoses that may correlate with these symptoms.

Problem Statement on case Andrew Chen

Andrew Chen is a 14-year-old male who presents to the clinic with his father with complaints of pain and swelling in his right ankle. He was playing in a basketball game last night when he drove for a layup, stepped on his opponent's foot and fell. He had his trainer look at his ankle and wrap it with an ACE wrap when it happened. He took the ACE wrap off last night in order to shower and forgot to put it back on. He did ice and elevate his leg when he laid down. He is unable to bear weight at this time due to the pain. He took Ibuprofen last night and this morning with some relief.

Management Plan on case Andrew Chen

• HPI:
• PRIMARY
• DIFFERENTIALS:
• MEDICATIONS:
• EDUCATION:
• ANCILLARY TESTS:
• REFERRALS:
• FOLLOW UP:
• SOCIAL DETERMINANTS OF HEALTH:
• HEALTH PROMOTION:
• RISK FACTOR:
• Ankle Injury:
• REFERENCES

Electronic Medical Record on case Andrew Chen

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