Pre Brief
In this case study, you will complete the Plan My Exam activity to organize the exam procedures you will use into a sequence that moves smoothly from head to toe by mapping them to the region of the body where you will perform them. After you have planned your exam, you will enter the clinic room and conduct a Comprehensive Assessment by interviewing and examining your Digital Standardized Patient. When collecting information for the comprehensive assessment, be sure to include the following:
• Current Illnesses
• Past Illnesses
• Chronic Illnesses
• Past Medical History
• Injuries and Treatments
• Hospitalizations/Surgeries
• Environmental/Food/Drug Allergies
• Current Medications/Herbal Remedies/Health Supplements
• Past Medications
• Habits/Drug and Alcohol Use
• Family Medical History
• Psychosocial/Cultural/Spiritual History
• Sexual History
• Obstetric History
As you complete the case study this week, be cognizant of the time that it takes you to conduct the history and physical. In family practice, you are generally allocated a total of 15-minutes for an entire patient visit, which includes taking a history, performing a physical examination, and developing/implementing a treatment plan. You also need to incorporate health promotion into the visit when possible. Be certain to follow a systematic approach during your interview and inquire about each system on the ROS. During the physical exam, be sure to apply the examination skills that you have learned in this course to assess your virtual patient.
Ms. Tina Jones is a pleasant, 29-year-old African American single woman who presents for a pre-employment physical. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview. Reason for visit: Patient requests a complete health assessment for a pre-employment.
Results Included:
Experience Overview
Transcript
Subjective
Data
Collection
Objective
Data
Collection
Documentation
/
Electronic
Health
Record
Plan
My
Exam
Self –
Reflection
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