Performance Overview on Case Melissa Stewart

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

History Notecard on case Melissa Stewart

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. (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

Problem Statement on case Melissa Stewart

This is a 14 y.o F presenting with acute onset of confusion and lethargy this morning. She is positive for polyuria, polydipsia, and polyphagia for the past couple of weeks. She is hypotensive, tachycardic, and tachypneic. Exam findings are notable for AOx1, decreased skin turgor, delayed capillary refill, dry mucous membranes, fruity-smelling breath, and an early systolic heart murmur. She had a URI 3 weeks ago. She has a family history of "sugar problems" with her paternal grandfather.

Management Plan on case Melissa Stewart

1: Primary Diagnosis with ICD-10 code, rationale and resources.

2. Medications including OTC, dosage, pt. education, ancillary tests, referrals, and follow-up:

3. Completed Hx notes & Problem Statement in designated area (2.5 each area)

4. Social Determinants of Health to consider, Health Promotion and Pt risk factors

REFERENCES

Electronic Medical Record on case Melissa Stewart

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