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A medical test bank for iHuman Assignment. It contains a patient's medical history, symptoms, and physical examination. designed to help medical students prepare for exams and assignments related to patient diagnosis and treatment.
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Week 7 iHuman Assignment – Evita Alonso 48-year-old female 5’6” 170 lbs. Reason for encounter: “My stomach has really been hurting over the last two days and I haven’t been able to go to work.” Questions: How can I help you today? My stomach has really been hurting over the last two days and I haven’t been able to go to work. Any other symptoms or concerns? I’ve vomited three times in the last two days and haven’t felt like eating anything. I’ve only been drinking water and Gatorade, so I’m really only throwing up clear-looking liquid. How severe is your nausea and/or vomiting? Well, I’m not keeping much of anything down. Does anything make your nausea and/or vomiting better or worse? No. The nausea is pretty much there all of the time. What treatments have you had for your nausea and/or vomiting? Antacids – but that didn’t help/ Does the pain in your abdomen keep you from sleeping? Yeah, it’s gotten bad over the last two days. I do get some sleep though. Have you been having fevers? Yes, off and on over the last two days. I’ve felt feverish. I haven’t taken my temperature, but it is definitely up. Do you have diarrhea? No. Have you lost weight? Yes. My weight loss program is going really well. 15 pounds since I was here last. Look at my chart. I’m proud of that. 4 months ago – Weight 185 lbs. Have you had any yellowing of the skin or eyes (jaundice)? No. What treatments have you had for your abdominal pain? Nothing really. I have taken antacids and ibuprofen, but neither seems to help much. O=Onset, circumstances surrounding start of symptom
Yeah, now that you mention it. They’ve been more pale than is usual for me. How severe (1-10 scale) is your abdominal pain? It starts as a 2 or 3, and gets up to a 6 or 7. Right now, it is about a 3 to 4. Do you have any abdominal bloating? In addition to the pain, maybe a little bit of fullness – like I can’t hold my tummy in. Is the pain in your abdomen superficial (on the surface) or deep inside? Deeper inside. Have you had pain in your abdomen before? A few times over the past year I’ve had pain like this, but it’s always gone away on its own after a day or so. It never got this bad. Past Medical History No Patient Record – Obtain history Have Patient Record – Update allergies, medications, OTC drugs Any new or recent change in medications? No. Are you taking any over-the-counter or herbal medications? Just antacids, ibuprofen, and a daily multivitamin. I taken ibuprofen 400 mg three times a day when I need it for my knee stiffness – that seems more often theses days. Any new medical issues or diagnoses since your last visit? I’m hoping you can help figure out why I don’t feel well today, but nothing else since my last visit. Do you have any allergies? Not that I know of. Can you tell me about your diet? What do you normally eat? I try to provide healthy, balanced meals for my family – pretty much along the lines of the Mediterranean diet – and I cut out the fast food as part of my weight loss program. Do you drink caffeinated beverage or eat chocolate? No. Do you drink alcohol? If so, what do you drink and how many drinks per day? I have a glass of wine most every night with dinner. The last 2 days I haven’t had any. Family History No Patient Record – Obtain history Dad: Heart Disease and Peptic Ulcers Mom: Breast Cancer – been under control for a long time. She also had her gallbladder removed due to stones. Grandparents: Not aware of grandparents health Social History No Patient Record – Obtain history
Have Patient Record – Update if major change in: living situation, death of partner, loss of job, etc. ROS Questions for systems not addressed in HPI Do you have problems with nausea, vomiting, constipation, diarrhea, coffee ground in your vomit, dark tarry stool, bright red blood in your bowel movements, early satiety, or bloating? Some of that. Didn’t I tell you about all that already? Do you have any problems with an itchy scalp, skin changes, moles, thinning hair, or brittle nails? No. Do you have any problems with fatigue, difficulty sleeping, unintentional weight loss or gain, fevers, or night sweats? Some of those. Do you have any problems with headache that don’t go away with aspirin or Tylenol (acetaminophen), double or blurred vision, difficulty with night vision, problems hearing, ear pain, sinus problems, chronic sore throats, or difficulty swallowing? Uh…no. Do you experience chest pain discomfort or pressure, pain/pressure/dizziness with exertion or getting angry; palpitations; decreased exercise tolerance; or blue/cold fingers and toes? Uh…no. Do you experience shortness of breath, wheezing, difficulty catching your breath, chronic cough, or sputum production? Nope. When you urinate, have you noticed any pain, burning, blood, difficulty starting or stopping, dribbling incontinence; urgency during day or night, or any changes in frequency? Nope. Do you have problems with muscle or joint pain, redness, swelling, muscle cramps, joint stiffness, joint swelling or redness, back pain, neck or shoulder pain, or hip pain? A little knee stiffness from time to time. Nothing else though. Do you have problems with dizziness, fainting, spinning room, seizures, weakness, numbness, tingling, or tremor? No. Do you have problems with heat or cold intolerance, increased thirst, increased sweating, frequent urination, or change in appetite? No sweating or peeing a lot, but who wants to eat when they are throwing up? Has your level of activity recently changed? Nope. Do you have any problems with nervousness, depression, lack of interest, sadness, memory loss, or mood changes, or ever hear voices or see things that you know are not there? Nope. Physical Examination Temperature: 100.4 F (38.0 C) Pulse: 104 regular rhythm, normal strength
that the pain radiates to her right shoulder at times. Family history is positive for: peptic ulcers (father) and biliary disease (mother). Physical examination reveals right upper abdominal tenderness and guarding, positive Murphy’s sign, mild scleral icterus, fever (100.4 F), tachycardia, and orthostatic hypotension. General: Patient is an overall healthy obese 48-year-old female who reports right upper abdominal pain, located under her ribs that is felt deeper inside. It is rated as 3-4 abdominal pain currently, that begins as a 2-3 and gets as high as a 6-7. She admits that the abdominal pain began about two weeks ago, which started as much less intense and then got progressively more frequent and more painful. The last two days have been dreadful with vomiting and poor appetite. Patient experience prior abdominal pain a few times over the past year, but never to this severity – it always resolved within a day or so. Pain is constant now. Occasionally pain radiates to her right shoulder. The pain is described as a crampy, gnawing ache that is present all the time. HEENT/Neck: Patient denies any double or blurred vision, difficulty with night vision, problems hearing, ear pain, sinus problems, chronic sore throats, or difficulty swallowing. Cardiovascular: Denies chest pain discomfort or pressure, pain/pressure/dizziness with exertion or getting angry; palpitations; decreased exercise tolerance; or blue/cold fingers and toes. Patient reports feeling lightheaded. Respiratory: Patient denies shortness of breath, wheezing, difficulty catching your breath, chronic cough, or sputum production Gastrointestinal: Patient reports abdominal pain, associated with vomiting. Positive abdominal bloating and feelings of fullness. At first, eating made the pain worse and then not eating anything makes her throw up and the pain worse. Antacids didn’t help. Reports more pale color stools lately. Abdominal pain is not relieved after a bowel movement. Patient follows a Mediterranean diet and cut out fast foods as part of her weight loss program. Denies drinking caffeine or eating chocolate. Patient reports drinking one glass of wine with dinner each night. Gastrourinary: Denies frequent urination, any pain, burning, blood, difficulty starting or stopping, dribbling incontinence; urgency during day or night, or any changes in frequency Musculoskeletal: Reports knee stiffness from time to time. Denies any problems with muscle or joint pain, redness, swelling, muscle cramps, joint swelling or redness, back pain, neck or shoulder pain, or hip pain. No change in level of activity. Neurologic: Patient denies any problems with dizziness, fainting, spinning room, seizures, weakness, numbness, tingling, or tremor. Integumentary: Denies any problems with an itchy scalp, skin changes, moles, thinning hair, or brittle nails. Psychiatric: Patient denies any problems with nervousness, depression, lack of interest, sadness, memory loss, or mood changes, or ever hear voices or see things that you know are not there
Endocrine: Deferred. Hematologic: Deferred. Allergic/Immunologic: Patient denies any allergies. Past Medical History: PMH: Occasional heartburn. Bilateral knee pain and stiffness with frequent use of ibuprofen. OB/GYN History: Regular menses. Spouse had vasectomy about eight years ago. Hospitalizations/Surgeries: G3P3, vaginal deliveries without complications. Tubal ligation after the birth of her last child. No other surgeries. Preventative Health: Yearly routine well exams. PAP smear and mammogram recently done. Influenza and Covid vaccines are up to date. Medications: Patient denies any prescription medications. She reports taking over-the-counter vitamins, ibuprofen 400 mg PO three times daily as needed for knee pain, and antacids as needed for heartburn. Allergies: Patient denies any allergies to medications. Social History: Patient denies the use of tobacco or drugs. She admits to one glass of wine with dinner most nights. Patient follows a Mediterranean diet. She takes daily walks and works out at the gym with light weights three times per week. Patient has regular life challenges and family time helps reduce stress. She is an Army Lieutenant Colonel and lives in off-base private housing. Patient is married for 18 years and has three children, all of which are doing well in school and active in sports. Her parents live three hours away. Family History: Patient's father reports Obesity, Hypertension, Depression, and whatever else is previously listed in his chart. Previous Records indicate: Mother (69): Breast cancer in remission, S/P cholecystectomy for cholelithiasis Father (70): Heart disease, peptic ulcer disease Grandparents: Not aware of grandparents’ health. Children: 3 Children, all alive and well.
Select Final Diagnosis Management Plan Template Primary Diagnosis with ICD-10 Code:
confusion. The fundamental significance of this disorder is that it can be extremely effectively treated, if properly managed (Ahmed, 2018). This diagnosis is most consistent, given the patient’s symptoms, physical examination findings, and test results. Patient has progressive, intermittent right upper quadrant abdominal pain for the last two weeks, with occasional pain that radiates to the right shoulder. There is right upper quadrant tenderness and guarding. Patient has nausea, vomiting, and poor appetite for the last two days. Pain with eating, that was initially provoked by fast foods, and now occurring with all food intake. Patient has feelings of lightheadedness, fever of 100 F, tachycardia, mild sclera icterus, positive Murphy’s sign, and a family history of biliary disease. Patient’s abdominal ultrasound shows Cholelithiasis with probable choledocholithiasis with extra- and intrahepatic biliary tree dilation. CBC with diff results show borderline leukocytosis with neutrophila and mild left shift with WBC of 12.7. Patient has elevated BUN/Create level, abnormal liver enzymes which indicated obstructive pattern, and urinalysis shows elevated specific gravity and bilirubinuria. Differential Diagnoses with Rationale:
Education: Importance of follow-up care Follow and maintain a healthy diet Avoid fried foods, foods high in fat, foods high with refined carbohydrates Eat foods that a high in fiber and healthy fats Avoid alcohol Drink plenty of fluids Exercise regularly for weight loss Social Determinants of Health to Consider, Health Promotion, & Patient Risk Factors Lifestyle Changes Dietary/Nutrition Counseling Exercise Management and Regimen References Ahmend, M. (2018). Acute cholangitis – an update. World Journal of Gastrointestinal Pathophysiology, 9 (1), 1-7. https://doi.org/10.4291/wjgp.v9.i1.1. Costi, R. , Gnoochi, A., DiMario, F., & Sarli, L. (2014). Diagnosis and management of choledocholithiasis in the golden age of imaging, endoscopy, and laparoscopy. World Journal of Gastroenterology, 20 (37), 14382-13401. https://doi.org/10.3748/wjg.v20.i37.13382. Gallaher, J. R., & Charles, A. (2022). Acute cholecystitis: A review. JAMA, 327 (10), 965-975. https://doi. org/10.1001/jama.2022.2350. Malik, T. F., Gnanapandithan, K., & Singh, K. (2022). Peptic ulcer disease. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih/gov/books/NBK534792/. Szatmary. P., Grammatikopoulos, T., Cai, W., et al. (2022). Acute pancreatitis: Diagnosis and treatment. Drugs. 82 , 1251-1276. https://doi.org/10.1007/s40265-022-01766-4.
