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IHuman Case EVAN TYSON IHUMAN CC: TIRED AND PEEING
AT NIGHT CASE STUDY EXPERT
FEEDBACK (ANSWERS)
Performance Overview for Stephanie Piccolo on case Evan Tyson
The following table summarizes your performance on each section of the case,
whether you completed that section or not.
Time spent: 2hr 9min
16sec Status: Submitted
Case Section Status Your Score Time^ spent^ Performance^ Details Total Score 86% History Done 92% (^) 50min 38sec 96 questions asked, 23 correct, 2 missed relative to the case's list Physical exams Done 82% 25min 34sec 49 exams performed, 15 correct, 1 partially correct, 2 missed relative to the case's list Key findings organization Done 19sec 8 findings listed; 11 listed by the case Problem statement Done 5min 9sec 97 words long; the case's was 86 words Differentials Done 67% 7min 43sec 4 items in the DDx, 2 correct, 1 missed relative to the case's list Differentials ranking Done 100% (lead/alt score) 67% (must not miss score) 20sec Tests Done 100% 3min 37sec 7 tests ordered, 5 correct, 0 missed relative to the case's list Diagnosis Done 100% 6sec Management plan Done 9sec 2 words long; the case's was 63 words Exercises Done 83% (of scored items only) 13min 41sec 5 of 6 correct (of scored items only)
History Notecard by Stephanie Piccolo on case Evan Tyson
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 =tired
Sx
=erectile
dysfunction
Sx
=blurry
vision
Sx
=polyuria
Sx
=polydy
Onset week/months few months not
sure
months months
Location generalized penis both
eyes
generalized generaliz
Duration ongoing lasts less
than 5 mins
normal
eye
exam
last
months
ongoing ongoing
Characteristics fatigue, tired
all the time,
can't get
going
everytime
when
having sex
blurry
vision
getting
worse
7 - 8 times
during day,
3 - 4 times at
night
very thir
Aggravating n/a n/a n/a unknown unknow
Relieving n/a n/a n/a unknown unknow
Timing /
Treatments
all the time n/a n/a n/a n/a
Electronic Health Record by Stephanie Piccolo on case Evan Tyson
Pt 61 - year-old male presents for few months onset of polydypsia, polyuria, nocturia, weight
loss 4 - 5lbs, increased fatigue, erectile dysfunction, blurry vision, increased appetite, and
numbness and tingling feet. He reports drinking 4L of water a day along with urinating 7 - 8
times during the day and 3 - 4 times at night. Significant FMH of heart disease and sister with
new diagnosis of diabetes. He states he has decreased his exercise d/t tiredness and his diet
could be better. On exam, thyroid is slightly enlarged, BP is elevated 130/75, decreased b/l
monofilament test response and decreased b/l lower extremity vibration test.
see Canvas
History of Present Illness
Category Data entered by Stephanie Piccolo Reason for Encounter Increased urinating and fatigue History of present illness Pt presents for few months onset of polydypsia, polyuria, nocturia, weight loss of 4 - 5lbs, increased fatigue, erectile dysfunction, blurry vision, increased appetite, and numbness and tingling in b/l feet
Past Medical History
Category Data entered by Stephanie Piccolo Past Medical History none Hospitalizations / Surgeries none
Medications
Category Data entered by Stephanie Piccolo Medications multivitamin and supplements
Allergies
Category Data entered by Stephanie Piccolo Allergies none
Preventive Health
Category Data entered by Stephanie Piccolo Preventive health all immunizations up to date
Family History
Category Data entered by Stephanie Piccolo
Electronic Health Record by Stephanie Piccolo on case Evan Tyson
Family History Father- deceased at 55 - MI. mother-alive- CHF, kidney disease. Sister- obesity, diabetes. Children- healthy
Social History
Category Data entered by Stephanie Piccolo Social History non-smoker, does not drink, no illicit drug use. married 45 years, 2 adult children. Retired veteran.
Physical Exams
Category Data entered by Stephanie Piccolo General Well-nourished, no distress, overweight. Skin Warm, dry, no lesions. Skin turgor intact, no bruising. HEENT / Neck Head normocephalic, atraumatic. No edema, masses, deformities, tenderness or lesions of the head and neck when palpated. Frontal and maxillary sinuses non-tender. Full ROM of head and neck. Thyroid palpable, midline, slightly enlarged. Fundoscopic exam no papilledema, cotton wool spots, AV nicking, or flame hemorrhages. Oropharynx intact, no erythema. Cardiovascular S1 and S2 regular rate and rhythm, no extra heart sounds or murmurs. Chest / Respiratory B/l lung sounds clear. Chest rise symmetric, unlabored, no use of accessory muscles. AP diameter normal. No tenderness or masses noted upon palpation of chest. Abdomen Abdomen soft, nontender, obese. Bowel sounds normoactive and present in all four quadrants. Liver palpated non hepatosplenomegaly, no masses or herniations. No tympany or dullness. Genitourinary / Rectal Male genitalia intact, no discharge or drainage from penile meatus. Musculoskeletal / Osteopathic Structural Examination Full ROM of all extremities. 5/5 strength on all extremities. Stability intact. No gait or posture abnormalities. Neurologic ASOx4. DTR 2+ in triceps, biceps, radial, patella, and Achilles. B/l diminished lower extremity vibratory sensation to the level of the ankles. B/l monofilament test diminished response. Psychiatric Pleasant, calm, cooperative. Answers questions appropriately. Behavior appropriate for age. Lymphatic All lymph nodes palpable, no lymphadenopathy.
