Performance Overview for Ariadna Zarzuela on case Dorothy Jones V5
The following table summarizes your performance on each section of the case, whether
... [Show More] you completed that section or not.
Time spent: 2hr 15min 2sec Status: Submitted
Case Section Status Your
Score Time spent Performance Details
Total Score 78%
History Done 68% 24min 32sec 120 questions asked, 27 correct, 13 missed relative to the expert's list
Physical exams Done 94% 21min 24sec 71 exams performed, 12 correct, 1 missed relative to the expert's list
Key findings organization Done 1min 8sec 16 findings listed; 12 listed by expert
Problem statement Done 5min 10sec 69 words long; expert's was 37 words
Diagnosis Done 100% 6sec
Management plan Done 43min 15sec 363 words long; expert's was 153 words
Exercises Done 63%
(of scored items only) 13min 47sec 5 of 8 correct (of scored items only)
History Notecard by Ariadna Zarzuela on case Dorothy Jones V5
Use this worksheet to organize your thoughts before developing a differential diagnosis list.
1. Indicate key symptoms (Sx) you have identified from the history. Start with the patient's reason(s) for the encounter and add additional symptoms obtained from further questioning.
2. Characterize the attributes of each symptom using "OLDCARTS". Capture the details in the appropriate column and row.
3. Review your findings and consider possible diagnoses that may correlate with these symptoms. (Remember to consider the patient's age and risk factors.) Use your ideas to help guide your physical examination in the next section of the case.
HPI Sx = Sx = Sx = Sx = Sx = Sx =
Onset
Location
Duration
Characteristics
Aggravating
Relieving
Timing / Treatments
Severity
Problem Statement by Ariadna Zarzuela on case Dorothy Jones V5
Patient Dorothy Jones is a 54 y/o female who presents to the clinic c/o Abdominal pain that began 3 days ago after dinner. Pt states food makes it worse and vomiting improves it, she appears to be uncomfortable. Reports no bowel movements or passing flatus for 2 days. Upon abdominal assessment, patient was found to have no bowel sounds, peri umbilical discomfort on palpation, and abdominal distention with tympany.
Management Plan by Ariadna Zarzuela on case Dorothy Jones V5
Dorothy Jones 54 y/o woman with a history of two prior abdominal surgeries (hysterectomy and cholecystectomy) who presents with new-onset mid-abdominal pain, distention, nausea/vomiting, and obstipation.
History of present illness: Abdominal pain not radiating as stated by patient since 3 days ago after eating dinner. Worsened with meals, relieved by vomiting. Patient states she has not had a bowel movement or passed flatus in 2 days.
Past Medical Hx: hyperlipidemia, uterine fibroids, constipation, and hemorrhoids Past surgical Hx: Cholecystectomy 15 years ago and hysterectomy 2 years ago NKA
Current medications: Aspirin 81mg , Lipitor, 20mg and OTC citrucel (fiber supplement) No psychiatric history, vaccinations up to date
Family Hx: Patient denied any family history
Social Hx: Patient differed occupation information. former smoker for 20 years of half a pack a day but quit 15 years ago. Social drinker, Denies recreational drugs.
ROS
gen: looks uncomfortable and bloated skin: warm and dry
eyes: WNL Ear: WNL
nose/mouth/throat: WNL Breast: differed
Heme/lymp/endo: Hyperlipidemia cardiovascular: WNL
respiratory: WNL
gastrointestinal: Abdomen taut and distended, scars correlate with surgical hx. Mild discomfort throughout abdominal palpation, absent bowel sound on auscultation. Patient denies any radiation of pain. No bowel movement or flatus for 2 days genitourinary: denies any abnormalities
musculoskeletal: WNL neurological: WNL
psychiatric: denies any previous history
Objective:
V/S; B/p 128/72 HR 100bpm RR 18 bpm temp 37.0 BMI 26.6 HT66" Wht 165lb SpO 98%
Lab test ordered with results:
Abdominal x-ray: Small bowel obstruction CBC: mild hemo concentration
CMP: Elevated BUN/Creatine due to dehydration, low-normal potassium & hypochloremia consistent w/emesis Lipase: Normal
Urinalysis: Specific gravity high end of normal suggesting mild dehydration
Diagnosis:
Small Bowel Obstruction
Treatment:
Instruct patient to not eat or drink anything by mouth and send to ER for hydration and bowel management
Education:
Patient should exercise to increase peristalsis and balanced diet high in fiber and low in fat. Follow up: Once released from the ER call office to make a follow up appointment.
Quero, G., Covino, M., Laterza, V., Fiorillo, C., Rosa, F., Menghi, R., ... & Alfieri, S. (2021). Adhesive small bowel obstruction in elderly patients: a single-center analysis of treatment strategies and clinical outcomes. Scandinavian Journal of Gastroenterology, 56(7), 784-790.
Electronic Medical Record by Ariadna Zarzuela on case Dorothy Jones V5
History of Present Illness
Category Data entered by Ariadna Zarzuela
Reason for Encounter abdominal pain
History of Present Illness Abdominal pain not radiating as stated by patient since 3 days ago after eating dinner, relieved by vomiting
Past Medical History
Category Data entered by Ariadna Zarzuela
Past Medical History hyperlipidemia, uterine fibroids, constipation, and hemorrhoids
Hospitalizations / Surgeries Cholecystectomy 15 years ago, hysterectomy 2 years ago
Medications
Category Data entered by Ariadna Zarzuela
Medications Aspirin 81mg Lipitor 20mg
Citrucel-fiber supplement
Allergies
Category Data entered by Ariadna Zarzuela
Allergies NKA
Preventive Health
Category Data entered by Ariadna Zarzuela
Preventive health aspirin 81mg
Family History
Category Data entered by Ariadna Zarzuela [Show Less]