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Using the essаy spаce prоvided: Recоrd а cоmplete and thorough history of your encounter with Scenario A1, the well-child visit. Scenario A1 Reference Material Below: ------------------------------------------------------------------------------------------------- Door Chart & Learner Instructions Setting Pediatric Office; Well-child visit Arrived via private car with parent Patient Name: Jamila Sanzee Age: 6 months old (DOB: June 8th, 2025) Gender: Female Chief Complaint (per parent): “I’m here for her routine 6-month visit” Vital Signs: (if applicable) Temperature: 98*F/ 37*C Heart Rate: 130 beats / min (Range: 114-152) Blood Pressure: N/A Respiratory Rate: 34 breaths / min (Range: 31-52) Pulse ox: 99% on RA Weight: 17 lb, 1oz / 7.8 kg (76% percentile for age) Length: 27” / 68.5 cm (76% percentile for age) ________________________________________________________________________________________ Developmental Milestones (pre-filled) form for reference: Patient Vaccination Hx form for reference: Provided CDC Vaccine Schedule for reference:
Using the essаy spаce prоvided: Recоrd cоmplete аnd thorough admission orders for the patient with abdominal pain from Scenario C1. Scenario C1 Reference material below: Patient Door Chart and Note (for reference) Setting: Emergency Room Arrived via ambulance Patient Name: Rimona Castellano Age: 17 years old Gender: Female Chief Complaint: “My belly really hurts and I was hoping it would just go away.” Triage Vital Signs: Temperature: 98.9*F / 37 *C Heart Rate: 102 beats per minute Blood Pressure: 144/80 mmHg Respiratory Rate: 18 breaths per minute Pulse Oximetry: 99% on RA Weight: 112 lbs / 50.8 kg Height: 63 inches / 160 cm ____________________________________________________________________________________________ Scenario C1 - Patient Case History, Physical Exam, and Diagnostics Patient: Rimona Castellano Age: 17 yrs old CC: “My belly really hurts and I was hoping it would just go away.” History of Present Illness (HPI): Quality/Character: Sharp and stabbing Onset: 4 hours ago; sudden in onset Timing/Duration: Constant since onset; worsening since first noticed Region/Radiation: Low right-sided abdomen / pelvic area with radiation to the back Severity/Intensity: 10 out of 10, severe Aggravating Factors: The pain is aggravated by walking and changing positions Alleviating Factors: Tylenol did not help resolve the pain (last taken 2 hours ago). Precipitating Factors: Pt was walking down a flight of stairs right before this started. No preceding trauma, injury, or event otherwise reported. No recent surgery or medical procedure. Associated Symptoms: Pertinent Positive: +Nausea +Vomiting x 1 - Nonbilious, non-bloody vomiting Pt last ate any food/liquids last night around 8pm Pertinent Negative: No dysuria No urinary frequency No unusual vaginal discharge or bleeding LMP was 2.5-3 weeks ago, described as “normal” at that time No fever No recent change in appetite No constipation or diarrhea No recent or new sexual contact(s) No abdominal distension Past Medical History (PMHx): Illnesses/Injuries: Asthma, L-sided Ovarian Cyst (one time in 2024) no major medical intervention was needed Hospitalizations: None prior Surgical History: None Screening/Preventive History: Pt states she is up-to-date on most vaccinations and preventative screenings, including HPV, Tdap/Tetanus (last updated 3 years ago), but denies getting any influenza or COVID vaccinations yet this year Medications (Prescription, Over the Counter, Supplements): -OTC Tylenol for pain (Pt took 1000mg PO once 2 hours ago) -Albuterol MDI inhaler 90mcg/actuation - 1-2 puffs PO PRN asthma symptoms q 4-6 hrs Allergies (e.g. environmental, food, medication and reaction): -Morphine (causes sensation of itching all over and nausea) Family Medical History: Mother (alive, age 49) has history of “high blood pressure” Father (alive, age 50) has history of “high blood pressure, overweight, and high cholesterol” Brother (alive, 18) healthy No genetic disorders known in family Social History: Substance Use / Alcohol Use: No tobacco/vape, substance use, or alcohol use reported. Diet: Regular diet - (pt last ate last night at 8pm) Home Environment: Lives with parents in a two-story home Occupation: Student Leisure Activities: Running, volleyball, riding her bicycle, and surfing Exercise: Active Sleep: 7-8 hours per night Religion: Jewish Sexual/Women’s Health: Currently sexually active with her long-time boyfriend of 2 years. They use condoms for protection/birth control. LMP 2.5-3 weeks ago, normal menstrual cycles each month since age 15. G0P0. ROS (Review of Systems): General: No fever/chills noted. No weight loss/gain or night sweats. Skin: No rashes, jaundice, erythema, eczema, or skin changes reported. HEENT: No headache, neck pain/stiffness, no sore throat. No vision changes or congestion/runny nose. Respiratory: No cough, shortness of breath or wheezing. No DOE or orthopnea. Cardiovascular: No chest pain or palpitations. Gastrointestinal: See HPI and associated symptoms above. No blood in stool or melena reported. No diarrhea or constipation. Pt passing gas normally. Genitourinary: See HPI and associated symptoms above. No change in urination, dysuria, hematuria, or increased urinary frequency. Musculoskeletal: No joint, upper back, or neck pain reported. No joint swelling or warmth reported. No recent trauma or injury reported. No ROM limitations reported. Hematologic: No known easy bruising/bleeding, or gum bleeding. Neurologic: No HA, confusion, disorientation. No numbness or weakness. Physical Exam: Ultrasound Interpretation: “This transvaginal ultrasound with Doppler demonstrates an enlarged right ovary measuring (6.8 x 7.0 x 4.5 cm) that appears hyperechoic in nature. The right ovary has a more midline location than expected. There is a small amount of hypoechoic free fluid in the right pelvis. Spectral Doppler shows absent blood flow to the right ovary. No ovarian cyst, mass, or irregularity noted to the left ovary and no other visualized abnormalities seen in the visualized pelvis.” END OF CASE INFORMATION GYN Surgery Consultant Response and Recommendations (from a Text Message to you): “For patient Rimona Castellano, it looks like we can add this case immediately once the operating room is clean and ready. My team is finishing up a c-section delivery and will be available within 15 minutes. Please ensure that the patient is NPO effective immediately in preparation for surgery shortly. Additionally, since I don’t have the pt’s chart in front of me, I’ll also need you to place the following orders prior to this pt’s surgery: Please order a “blood type and screen” lab for pre-op purposes. We will need that lab before we go to surgery. Also, please order some morphine for her for pain control, as I’d like her comfortable coming into the operating room. Since she will be staying with us after surgery, please add any routine admission orders as you see necessary. For questions or concerns, please contact me.” Dr. Maribel Lee, MD - Gynecology Surgeon on-call
Pick а pаthоlоgy frоm your exаm and create a Diagnostic Schema/Mind Map below. Click here for a reference.