Week 4 Assignment 1: iHuman Simulation
i-Human Soap Note – Bobbie Case Study
Chief complaints (CC): Bobbie is 18 y/o student who presents with sudden onset of myalgias, pleuritic pain, SOB, and productive cough.
HPI: Bobbie had symptoms of the flu about ten days ago. He did not seek medical attention but now presents with the return of symptoms that appear worse. He reports fevers, chills, rigors, muscle aches, tender cervical lymph node, and right-sided chest wall pain aggravated by deep breathing and coughing. His cough is productive of thick yellow mucus, and he feels a bit winded when he climbs up or runs to class.
Assessment
Community-Acquired Pneumonia (CAP) (J18.9)
Rationale: CAP is pneumonia acquired outside healthcare facilities. However, it is the leading cause of morbidity, mortality, hospitalization, and increased care costs (Shoar & Musher, 2020). The disease is caused by streptococcus pneumoniae (pneumococcus) (Shoar & Musher, 2020). The clinical manifestation of community-acquired pneumonia ranges from mild to severe pneumonia. Pneumonia is characterized by productive cough, respiratory distress, fever, shaking chills, rigor, myalgias, and chest pains. The disease is considered the primary or final diagnosis because Bobbie is a college student living within the college environment. He might have acquired pneumonia after hanging out with friends. Also, the patient presents all the symptoms of community-acquired pneumonia during the hospital visit.
Pulmonary embolism (I26)
Rationale: pulmonary embolism is an illness caused by a blood clot that develops within the pulmonary artery in the lungs (Poyiadji et al., 2019). The symptoms of the disease relevant to the case study include cough, muscle aches, chest pains, and fever. The clinical manifestations make it possible to include pulmonary embolism as a differential diagnosis (Poyiadji et al., 2019). However, the patient only presents fewer symptoms that can be associated with pulmonary embolism. Symptoms such as chills and rigors are not related to pulmonary embolism. Thus, the disease cannot be considered the primary or final diagnosis.
Influenza (J10. 1)
Rationale: influenza is an acute respiratory disease caused by the influenza virus (Dolin, 2020). The disease is transmitted from one person to another through droplets made whenever people talk, sneeze, or cough (Dolin, 2020). The clinical manifestation of influenza is rapid onset of headache, myalgia, sore throat, weakness, fever, non-productive cough, and nasal discharge. Influenza risk factors include age (worse for children under two years and adults over 65), pregnancy, obesity, living conditions, and race (Dolin, 2020). The disease is ruled out by the patient’s history. Bobbie had flu over the last ten days and did not receive a vaccination or seek medication. However, most people get the flu once every few years. Thus, the flu could not have reappeared within ten days.
Covid-19 (Z20.822)
Rationale: Covid-19 is a communicable respiratory disease caused by the coronavirus (Poyiadji et al., 2019).The disease is transmitted from one human to the next through respiratory droplets produced whenever an individual with the virus sneezes or coughs (Poyiadji et al., 2019). The clinical manifestations or symptoms of the disease relevant to the case include cough, sore throat, myalgia, fever, respiratory distress, and nasal discharge. The clinical diagnosis can be considered because Bobbie presented most of the symptoms of upper respiratory infections.
Final Diagnosis: Community-Acquired Pneumonia (J18.9)
Plan
Pharmacology
Amoxicillin 1 g PO three times a day or
Azithromycin 500 mg once a day or
Non-Pharmacology
Stay hydrated – Bobbie should take plenty of fluids, including water, to loosen the mucus in the lungs.
Receive enough rest – Bobbie is not expected to resume work until the body temperature returns to normal or until the coughing stops.
Take steamy showers and use humidifiers to provide additional moisture.
Diagnostics
Urinary antigen testing (UAT) – An assay used to identify the C-polysaccharide antigen of pneumonia microbial in the patient’s urine. The test samples are easy to collect, and results are obtained in real-time.
PCR test for respiratory specimen – used to detect respiratory pathogens among patients suspected of community-acquired pneumonia.
Sputum culture and grain stain – a lab test that enables the physician to diagnose bacterial infections within the respiratory tract.
Blood culture – it is a laboratory test that involves obtaining blood cultures before antibiotic administration since some pathogens are linked with blood cultures.
Consults/Referrals
Not needed at this time.
Patient Education
You should rest until you feel better and not smoke within such a period. Smoking makes community-acquired pneumonia worse. Also, if the pneumonia is severe or linked to other diseases, the doctor might recommend being treated in the hospital (Shoar & Musher, 2020).
You should learn about the drug prescription (including its side effects) and how to adhere to the prescribed dosage. The antibiotics will significantly improve how the body fights pathogens (Shoar & Musher, 2020).
Maintain good health habits – this includes eating right, receiving sufficient sleep, and exercising to prevent community-acquired pneumonia and other related infections. Regularly talk about lifestyle changes with your doctor to improve your health.
Drink plenty of fluids, especially water, to stay hydrated. One way to know you are hydrated is when your urine is light yellow to almost clear.
Follow Up
Follow-up within two weeks to review the lab results and make medication changes. However, visit the care facility within 24 hours if the symptoms worsen.
References
Dolin, R. (2020). Seasonal influenza in adults: Transmission, clinical manifestations, and complications. UpToDate. https://www.uptodate.com/contents/seasonal-influenza-in-adults-clinical-manifestations-and-diagnosis#H3916408703
Poyiadji, N., Cormier, P., Patel, P. Y., Hadied, M. O., Bhargava, P., Khanna, K., … & Song, T. (2020). Acute pulmonary embolism and COVID-19. Radiology, 297(3), E335.
Shoar, S., & Musher, D. M. (2020). Etiology of community-acquired pneumonia in adults: a systematic review. Pneumonia, 12(1), 1-10.
Due: Sunday, 29 January 2023, 11:55 PM
Done: Make a submission
Value: 100 points
Due: 7
Gradebook Category: Assignments—iHuman Assignments
Introduction
The iHuman platform is an opportunity for you to interact with a simulated patient and gather data. When working in iHuman, practice as if this were a real patient. For example, the platform allows you to ask several questions when taking a patient history. In real life, you likely will be limited in time. Practice setting yourself a patient history time limit and work on being efficient in your clinical interview.
If you require technical support with the iHuman platform, use the iHuman Help Center to contact iHuman Technical Support directly. Technical support only includes a malfunction of the platform; they cannot help with issues involving content!
Instructions
In this assignment, you will review a patient scenario in iHuman. Please see the course announcement for the case assigned this week. Your deliverable for this assignment is a paper based on the iHuman Soap Note Template (Word).
Follow the requirements listed in the iHuman Soap Note Template.
When your iHuman Soap Note Template is complete, upload it to this assignment.
All papers must conform to the most recent APA standards.
Please refer to the Grading Rubric for details on how this assessment and plan is graded.
To Submit Your Assignment:
Select the Add Submissions button.
Drag or upload your files to the File Picker.
Select Save Changes.
Submission status
Submission statusSubmitted for gradingGrading statusGradedTime remainingAssignment was submitted 3 days 10 hours earlyLast modifiedThursday, 26 January 2023, 1:23 PMFile submissionsweek_4_i-Human_soap_note.docxTurnitin ID: 199997609915%26 January 2023, 1:23 PMSubmission commentsComments (0)
iHuman Moodle Rubric
CriteriaExceeds ExpectationsMeets ExpectationsNeeds ImprovementInadequateTotal PointsSubjective – 40%Determined by iHuman 40 pointsDetermined by iHuman 36 pointsDetermined by iHuman 32 pointsDetermined by iHuman 0 points40Objective – 25%Determined by iHuman 25 pointsDetermined by iHuman 22 pointsDetermined by iHuman 20 pointsDetermined by iHuman 0 points25Objective – 5% (Testing)Determined by iHuman 5 pointsDetermined by iHuman 4 pointsDetermined by iHuman 3 pointsDetermined by iHuman 0 points5Assessment—5%Three differential diagnoses are supported by findings and include worst-case scenario.
Rationale for differential diagnoses provided by scholarly resources.
5 pointsThree differential diagnoses include worst-case scenario, but one diagnosis might not be fully supported by findings.
Rationale for differential diagnoses provided by scholarly resources.
3 pointsDifferential diagnoses may or may not include worst-case scenario, and two differential diagnoses are not supported by findings.
Rationale for all differential diagnoses not provided by scholarly resources.
1 pointsFewer than three differential diagnoses identified, or differential diagnoses not supported by findings and do not include worst-case scenario.
Scholarly resources not provided or do not support differential diagnoses.
0 points5Plan—25%Comprehensive plan includes all components: Diagnostic testing Pharmacologic intervention Non-pharmacologic intervention Referrals Patient education Follow-up Appropriate and current guidelines cited.
25 pointsPlan missing one of the identified components: Diagnostic testing Pharmacologic intervention Non-pharmacologic intervention Referrals Patient education Follow-up Appropriate and current guidelines cited.
17 pointsPlan missing two of the identified components: Diagnostic testing Pharmacologic intervention Non-pharmacologic intervention Referrals Patient education Follow-up Guidelines are not current or appropriate for identified problem.
9 pointsPlan missing more than three of the identified components: Diagnostic testing Pharmacologic intervention Non-pharmacologic intervention Referrals Patient education Follow-up Guidelines for plan not cited.
0 points25Total Points100
