Description
NR509 Week 3 iHuman : Rebecca Fields
Case Instructions – Rebecca Fields (23 y/o, F)
Reason for Encounter: Fever and sore throat
Location: Outpatient clinic with x-ray, ECG, and lab capabilities
🩺 History
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Ask up to 120 focused questions—only present illness and relevant body systems are credited.
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Use open-ended starters like: “How can I help you today?” and “Any other symptoms or concerns?”
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Use the OLDCARTS method to structure the HPI.
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Complete medical, family, and social history plus review of systems (ROS).
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Record abnormal findings under Key Findings in the EHR.
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Only document findings actually discussed in the interaction.
🧪 Physical Exam
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Open the patient record to verify and document vital signs.
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Click and examine systems based on symptoms (e.g., ENT for sore throat).
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Avoid vague terms like “normal”; describe findings specifically.
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Record “Not assessed” if you skipped a body system—don’t falsely record “Negative”.
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Only objective findings belong in the Physical Exam section.
Patient History
🟢 | HPI | What brings you in today? | I’m having a really bad sore throat.
🟢 | HPI | Are you experiencing any other symptoms or concerns? | Yes, I’ve had some mild headaches that come and go. Also, the glands on both sides of my neck feel very swollen and tender. That’s about it.
🟢 | Symptom | Is your throat sore? | Yes.
🟢 | HPI | When did the sore throat begin? | It started suddenly about two days ago.
🟢 | HPI | Did anything happen that might have tri
ggered the sore throat? | Not really—it just began hurting on its own.
🟢 | HPI | Does anything help relieve your sore throat? | I wish something did.
🟢 | HPI | How would you rate the severity of your sore throat? | Honestly, it’s extremely painful—like an ice pick in my throat. It’s the worst I’ve ever had. On a scale of 1 to 10, it’s an 11.
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