History of prese Study guides, Class notes & Summaries

Vanessa Joubert Heart Failure History of Present Problem: JoAnn Smith is a 72-year-old woman who has a history of myocardial infarction (MI) four years ago and systolic heart failure secondary to ischemic cardiomyopathy with a current ejection fraction (EF) of only 15%. She presents to the emergency department (ED) for shortness of breath (SOB) the past three days. Her shortness of breath has progressed from SOB with activity to becoming SOB at rest. The last two nights she had to sleep in...

Narcotics or Sepsis? Pharmacology Clinical Reasoning Case Study -Brian Sanders, 34 years old History of Present Problem: Brian Sanders is a 34-year-old male who was evaluated in the emergency department (ED) earlier this morning for an abscess that was drained from his left thigh. He was given two tablets of hydrocodone-acetaminophen 5-325 mg and sent home with a prescription for #10 hydrocodone-acetaminophen 5-325 mg tablets to be taken PRN for pain every 4 hours. Eight hours after being d...

Pro Tip: Foundational questions about general well-being are important in assessing how a patient feels at the current moment. This creates a space for Tina to contextualize her current feeling in relation to a chief complaint. Example Question: What brings you in today? Finding: Asked about reasons for seeking treatment Finding: Reports worry that inhaler "isn't working like it usually does" (Available) Pro Tip: Initially establishing a chief complaint allows the patient to express...

Chief complaint “Pain in my lower back” History of Presenting Illness Tina Jones is 28 y/o African American female with a history of diabetes and asthma presenting to the clinic complaining of a lower back pain making it difficult to perform her activities of daily living. The pain started three days ago after she “tweaked” it lifting a box. She has been medicating herself with two over the counter Advil every 5-6 hours which does decrease her pain. Lying flat on her back also see...

Pediatric Asthma FUNDAMENTAL Reasoning Jared Johnson, 10 years old Primary Concept Gas Exchange Interrelated Concepts (In order of emphasis) 1. Inflammation 2. Clinical Judgment 3. Patient Education © 2016 Keith Rischer/ FUNDAMENTAL Reasoning: STUDENT Pediatric Asthma History of Present Problem: Jared Johnson is a 10 year-old African-American boy with a history of moderate persistent asthma. He is being admitted to the pediatric unit of the hospital from the walk-in clinic with an acute asthma ...

mplexiMedical Billing and Coding Certificate exam 1. Chief Complaint (element 1 of history): History of present illness, Review symptom, Past, Family, and Social history 2. History Levels (Element 2 of history) and Examination Levels (Element 3 of History): Problem focused, expanded problem focused, detailed, Comprehensive 3. Medical Decision Making Complexity Levels (element 4 of history): Straightforward, Low, Moderate, High 4. straightforward: Minimal diagnosis Minimal risk Mi...

Clinical Dilemma Activity: STUDENT Remain Intubated or Withdraw Life Support I. Scenario History of Present Problem: Joyce Johnson is a 58-year-old woman with a history of atrial fibrillation, COPD, and depression. A friend who had not heard from her for two days became concerned and went to her home. She found Joyce unresponsive on the floor of her living room. She had a large left middle cerebral artery (MCA) ischemic stroke. She is intubated and has remained in ICU since she was admitt...

Pediatric Asthma FUNDAMENTAL Reasoning - Jared Johnson, 10 years old / Pediatric Asthma History of Present Problem: Jared Johnson is a 10 year-old African-American boy with a history of moderate persistent asthma-Pediatric Asthma FUNDAMENTAL Reasoning Jared Johnson, 10 years old Primary Concept Gas Exchange Interrelated Concepts (In order of emphasis) 1. Inflammation 2. Clinical Judgment 3. Patient Education/ FUNDAMENTAL Reasoning: STUDENT Pediatric Asthma History of Present Problem: Jared Johns...

Pro Tip: Foundational questions about general well-being are important in assessing how a patient feels at the current moment. This creates a space for Tina to contextualize her current feeling in relation to a chief complaint. Example Question: What brings you in today? Finding: Asked about reasons for seeking treatment Finding: Reports worry that inhaler "isn't working like it usually does" (Available) Pro Tip: Initially establishing a chief complaint allows the patient to express...

ScribeAmerica Final Exam ED @ 2023 What are the 3 types of dispositions? - Answer Discharge, Admit, Transfer What does HPI stand for? - Answer history of present illness What does ROS stand for? - Answer review of systems The HPI and ROS are considered what type of information? - Answer subjective The physical exam is wh