{"id":35702,"date":"2024-10-22T19:13:05","date_gmt":"2024-10-22T19:13:05","guid":{"rendered":"https:\/\/www.writemyessays.app\/blog\/questions\/i-human-case-week-9-26-y-o-5-6-168-cm-122-0-lb-55-5-kg-reason-for-encounter-more-frequent-severe-headaches-location-outpatient-clinic\/"},"modified":"2024-10-22T19:13:05","modified_gmt":"2024-10-22T19:13:05","slug":"i-human-case-week-9-26-y-o-5-6-168-cm-122-0-lb-55-5-kg-reason-for-encounter-more-frequent-severe-headaches-location-outpatient-clinic","status":"publish","type":"questions","link":"https:\/\/www.writemyessays.app\/blog\/questions\/i-human-case-week-9-26-y-o-5-6-168-cm-122-0-lb-55-5-kg-reason-for-encounter-more-frequent-severe-headaches-location-outpatient-clinic\/","title":{"rendered":"i-Human Case Week #9 26 y\/o 5′ 6″ (168 cm) 122.0 lb (55.5 kg) Reason for encounter More frequent severe headaches Location Outpatient clinic"},"content":{"rendered":"
You will complete a comprehensive head-to-toe assessment for  i-Human Patients Assignment.<\/div>\n
 <\/div>\n
Note: You must achieve a total score of at least 70% in order to pass this Assignment. You must pass the Week 9 Assignment to pass the course. Carefully review the Assignment and the rubric to be sure you fully understand the requirements of this Assignment.<\/div>\n
 <\/div>\n
Please take your time to complete this assignment. If you have an issue with the technology, please reach out to Ihuman support. Once your assignment has been completed, please upload as required. You must also document in the EMR\/EHR system. This is part of the grading process. Review your rubric prior to completing the assignment to make sure you cover all of the requirements. <\/span>This will be a one time submission.<\/strong><\/div>\n
<\/p>\n
We are entering week 9. Please see below weekly announcement.  Only one more Ihuman assignment to go ?<\/div>\n
Welcome to Week 9. This week, you will explore methods for assessing the neurologic system. In order to help you prepare, you have several lecturio videos demonstrating the assessment techniques of the neurological system:<\/div>\n
 <\/div>\n
\n
Lecturio Resources<\/span>Links to an external site.<\/span><\/span><\/a><\/div>\n<\/div>\n
Week 9 Videos <\/div>\n
    \n
  • Reflex Testing<\/i> (09:00) <\/li>\n
  • Sensory Examination<\/i> (08:30) <\/li>\n
  • Tests for Cervical and Lumbar Radiculopathy<\/i> (07:18) <\/li>\n
  • Quick Review: Examination of the Motor Neurons<\/i> (02:36) <\/li>\n
  • Patient Introduction and Review of the Etiology of Headache<\/i> (02:30) <\/li>\n
  • Examination of the Cranial Nerves I\u2013VI<\/i> (11:12) <\/li>\n
  • Examination of the Cranial Nerves VII\u2013XII<\/i> (12:42) <\/li>\n
  • Examination of the Cerebellum<\/i> (09:18) <\/li>\n
  • Examination of Cortical Sensation<\/i> (05:12) <\/li>\n
  • Physical Findings in Meningitis<\/i> (02:30) <\/li>\n
  • Quick Review: Examination of the Cranial Nerves<\/i> (02:48) <\/li>\n
  • Nursing Assessment of the Neurological System: Theory and Glasgow Coma Scale<\/i> (GSC) (11:12) It is important to try and do well on the history and physical that are already calculated by I-human. \n

    It is so IMPORTANT to complete each section of the I-human. A lot of students missed the EMR section (Electronic medical Record). This is where you will document your subjective and objective data. Some students posted this documentation under the Management and plan section (you may have learned this in the I-human student overview) but I would not suggest that at all. If you post it there you MUST also post in the EMR section as that is where this information belongs <\/strong><\/span><\/p>\n

    Utilize your resources. Use your clinical guide to documentation text as a guide for documentation. <\/span><\/p>\n

    Some of main issues I found while grading these assignments are the following.<\/span><\/p>\n

      \n
    • Not following the grading rubric<\/span><\/li>\n
    • Loss of points because the EMR was left blank<\/span><\/li>\n
    • Management and plan: follow the grading rubric and make sure to use references to support your plan. You will also need to add rationales for your interventions. If you do not document, it then it was not done. <\/span><\/li>\n
    • ROS: provide detailed documentation (state what the pt c\/o and denies). <\/span><\/li>\n
    • Physical Exam (PE) Do not use WNL or no abnormal findings– this does not demonstrate critical thinking skills in regard to documentation. document the normal and abnormal findings. <\/span><\/li>\n
    • HPI: provide detailed documentation elaborating on the reason for the visit using old carts or locates<\/span><\/li>\n
    • EMR: the encounter reason: is the same as the chief complaint: this should only be a few words<\/span><\/li>\n
    • EMR section: Complete all sections<\/span><\/li>\n<\/ul>\n

       <\/p>\n

          EHR Documentation Tips<\/span><\/p>\n

        \n
      • Chief complaint (CC) is a BRIEF statement identifying why the patient is here – in the patient\u2019s own words – for instance “headache”, NOT “bad headache for 3 days\u201d. Sometimes a patient has more than one complaint.  For example, if the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom<\/span><\/li>\n
      • Use OLD CARTS to document history of present illness (HPI)<\/span><\/li>\n
      • Be sure to include all past medical history, medications, and allergies.<\/span><\/li>\n
      • Include reaction\/response to each allergen.<\/span><\/li>\n
      • Include dosage, frequency, length of time used and reason for use for each medication; also include OTC or homeopathic products.<\/span><\/li>\n
      • Social history may include but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as seat belt use all the time or functional smoke detectors in the house, etc.<\/span><\/li>\n<\/ul>\n

         <\/span><\/p>\n

          \n
        • Family history: parents, grandparents, siblings, and children. Include grandchildren if pertinent.<\/span><\/li>\n
        • In your review of systems (ROS), address all body systems that may help rule in or out a differential diagnosis. State what the patient tells you (pt c\/o or denies);. If a system is not reviewed: state not reviewed.<\/span><\/li>\n
        • Provide detailed documentation Information that should be gathered during the physical examination by inspection, palpation, auscultation, and percussion should be documented under physical exam. Limit physical exam documentation to findings pertinent to your focused assessment based on the chief complaint. If unable to assess a pertinent body system, write \u201cUnable to assess. Separate the assessment findings accordingly and be detailed. Describe findings; do not use WNL. Document detailed normal and abnormal findings. (Refer to your Clinical Guide to Documentation Text as well).<\/span><\/li>\n<\/ul>\n

           <\/span><\/p>\n

           <\/span><\/p>\n

          Key Findings<\/span><\/p>\n

           <\/span><\/p>\n

          As you are working on the case you can add key findings and you organize them based on the most important.<\/span><\/p>\n

          When coming up with the key findings consider the most important symptoms that would be pertinent in diagnosing the patient based on the final diagnoses\/working diagnoses provided in I-human.<\/span><\/p>\n

           <\/span><\/p>\n

           <\/span><\/p>\n

          Problem statement<\/span><\/p>\n

            \n
          • Use the information you have collected from the HER and document your problem statement. Consider the pertinent subjective and objective data findings, demographic information (name, age etc),<\/span><\/li>\n<\/ul>\n

             <\/span><\/p>\n

            Management and plan<\/span><\/p>\n

              \n
            • This should include the following: diagnostic test and labs that are ordered. Medications (RX and OTC), Patient education, Referrals (if none- state that) and follow-up (this should include a realistic time frame) and also discuss when the patient should seek emergent care (document signs and symptoms that would warrant follow-up).<\/span><\/li>\n<\/ul>\n

               <\/span>I hope that you find this helpful.<\/span><\/p>\n<\/li>\n

            • \n
              <\/p>\n

              I will have all grades posted for Week 7 by the end of the day.  There has been a range of grades for week 7, with grades as high as 100%. <\/p>\n

              I encourage each of one you do your best on Week 9. Please review my comments on your assignment.<\/p>\n

              The mandatory pass grade for week 9 has been lowered to 70 for this semester<\/strong>.<\/p>\n

              Please contact me if you have any questions<\/p>\n

              <\/span><\/div>\n

              This topic is closed for comments.<\/span><\/span>
              <\/span><\/p>\n<\/li>\n

            • \n

              <\/span><\/span><\/span><\/p>\n

                \n
              • Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023).\u202fSeidel’s guide to physical examination: An interprofessional approach<\/em>\u202f(10th ed.). Elsevier Mosby. \n
                  \n
                • Chapter 7, \u201cMental Status\u201d 
                  This chapter revolves around the mental status evaluation of an individual\u2019s overall cognitive state. The chapter includes a list of mental abnormalities and their symptoms. <\/li>\n
                • Chapter 23, \u201cNeurologic System\u201d 
                  The authors of this chapter explore the anatomy and physiology of the neurologic system. The authors also describe neurological examinations and potential findings. <\/li>\n<\/ul>\n<\/li>\n
                • Sullivan, D. D. (2019).\u202fGuide to clinical documentation<\/em>\u202f(3rd ed.). F. A. Davis Company. \n
                    \n
                  • Chapter 2, \u201cThe Comprehensive History and Ph<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n

                    <\/strong><\/div>\n

                     <\/div>\n","protected":false},"excerpt":{"rendered":"

                    You will complete a comprehensive head-to-toe assessment for  i-Human Patients Assignment.   Note: You must achieve a total score of at least 70% in order to pass this Assignment. You must pass the Week 9 Assignment to pass the course. Carefully review the Assignment and the rubric to be sure you fully understand the requirements […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","template":"","meta":[],"disciplines":[13],"paper_types":[],"tagged":[],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/questions\/35702"}],"collection":[{"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/questions"}],"about":[{"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/types\/questions"}],"author":[{"embeddable":true,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/comments?post=35702"}],"version-history":[{"count":0,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/questions\/35702\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/media?parent=35702"}],"wp:term":[{"taxonomy":"disciplines","embeddable":true,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/disciplines?post=35702"},{"taxonomy":"paper_types","embeddable":true,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/paper_types?post=35702"},{"taxonomy":"tagged","embeddable":true,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/tagged?post=35702"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}