iHuman

iHuman

1. History:
a. Who is your patient? JP is a 49-year-old-patient with known colon cancer. If we don’t have this
information.
i. Age 36
ii. Gender Male
iii. Ethnicity __
2. Chief Complaint (CC): ALWAYS ASK! 2 Questions
a. How can I help you today? Fever on and off for last 3 weeks
b. Any other symptoms or concerns? Dry cough and get winded walking up stairs
3. History of Present Illness (HPI): Do OLDCARTS for every symptom presented/uncover.
a. OLDCARTS, 7 Questions for each symptom present!
i. O = Onset, setting, circumstances. 3 weeks ago
ii. L = Location
iii. D = Duration 3 weeks
iv. C = Characteristics
v. A = Aggravating/Alleviating – has not taken anything
vi. R = Radiation
vii. T = Treatments
viii. S = Severity – fever comes and goes
b. Cough- started couple of weeks ago. Around the same time as when he started feeling winded.
c. Nothing makes it better or worse. Albuterol inhaler didn’t do anything.
d. Not coughing up sputum
e. No tx
f. No fam with similar sx
g. No pattern

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SOB
Onset couple of weeks ago. Came on gradually and sometime after the fever started. There wasn’t.
particular even. Its just hat I first noticed it walking up the stairs at homeand work
It gets worse when im doing something. I tried using a friends albuterol inhaler but didn’t help
SOB at rest
SOB when lying down
SOB on exertion- noticed first when going u0p the stairs- and then started getting SOB while waljking
on flat ground. Now just walking 20 feet on flat ground at the plant makes me winded. Def problem
since manager thinks its affecting my work performance.
Duration- not getting any better
4. Past Medical History (PMH): 3 Questions for Focus (seen recently), 7 Question for Comprehensive (new)
a. ALWAYS UPDATE!
i. Allergies NKDa
ii. Prescription medications
iii. Over the counter (OTC) medications
b. If NOT in the Chart:
1
This study source was downloaded by 100000862437458 from CourseHero.com on 02-19-2023 12:44:15 GMT -06:00
https://www.coursehero.com/file/191493234/iHumandocx/
i. Medical, surgical, dental Chlamydia 3 years ago
ii. Obstetric
iii. Psychiatric
iv. Hospital admission
5. Travel AZ few months ago and was there for 1 month. Beijing 10 years ago
6.
7. Family History: 1-2 Questions
a. ALWAYS ask about genetic medical problems if NOT in the chart!
b. Father smokes, emphysema
c. Mom – HTN Breast cancer. Alive.
d. Grandparents unknown
e. Brother asthma- army
f.
g. If NO CHART available. Ask about family members (3 generations) back. Medical issues, age of
death.
8. Social History: 4 Questions.
a. ALWAYS UPDATE:
i. Tobacco yes. 1 or 2 cigs maybe ½ pack each week. 5 years
ii. Recreational drugs No
iii. Alcohol- couple of beers a week
iv. Sexual activity and precautions. With men. Regular basis, uses condoms, more than 1 in the
last year.
b. If not in the chart:
i. Educational level degree in chemical engineering
ii. Employment quality control for a manufacturer of latex
iii. Home Environment
9. Review of Systems (ROS): MAX of 13 Questions (yes or no questions). A system above and below.
Constitutional- denies
trouble sleeping,
sweating, fatigue and
fever
Hematology/Lymphatic￾no
Cardiac no CP, but cant
exercise now.
Immunologic:/Allergies
none. fever
Endocrine- none
Integumentary- flakiness
of my skin in a couple of
places. Dry lately.
ENMT n/a Musculoskeletal no
Eyes none Neurological n/a
Gastrointestinal N/a Psychiatric none
Genitourinary No Respiratory + SOB,
Cough, denies sputum
History of Present Illness:
This is an 18-year-old male college student with a history of childhood asthma who presents with acute
onset of a non-productive cough, sore throat, fatigue, myalgias and headache for 4 days. He reports a sick
2
contact and has not had an annual flu vaccination or Covid booster. Physical examination reveals a
temperature of 101, tachycardia, erythematous pharynx and anterior cervical lymphadenopathy, but
negative for adventitious breath sounds and hepatosplenomegaly.
iHUMAN MODULE

Tips & Tricks (under Help)
Pulse: Adult: Radial pulse (listen for 30 seconds).
Blood Pressure: Pump up no more than 30 over the heart rate.
Auscultation
3
iHUMAN STEPS
HISTORY
1. History and Chief Complaint:
a. Open EHR for a Baseline!
i. History: What was going on with him or her last time they came in?
ii. Physical Exam
4

1. Vital Signs: Normal
HR 60-100
RR 12-20
O2 >95%
Temperature 97.5°F to 98.9°F
iii. Plan: Did you do everything on the plan?
b. Current Visit:
i. What is given? Use this area to document.
2. History of Present Illness (HPI): Do OLDCARTS for every symptom presented/uncover.
a. History (Hx) Notes: Tab below
i. Document the symptoms and do OLDCARTS
ii. Start asking your questions.
b. OLDCARTS, 7 Questions for each symptom present!
i. O = Onset, setting, circumstances.
ii. L = Location
iii. D = Duration
iv. C = Characteristics
v. A = Aggravating/Alleviating
vi. R = Radiation
vii. T = Treatments
viii. S = Severity
3. Past Medical History (PMH): 3 Questions for Focus (seen recently), 7 Question for Comprehensive (new)
a. ALWAYS UPDATE!
i. Allergies
ii. Prescription medications
iii. Over the counter (OTC) medications
b. If NOT in the Chart:
i. Medical, surgical, dental
ii. Obstetric
iii. Psychiatric
iv. Hospital admission
4. Family History: 1-2 Questions
a. ALWAYS ask about genetic medical problems if NOT in the chart!
b. If NO CHART available. Ask about family members (3 generations) back. Medical issues, age of
death.
5. Social History: 4 Questions.
a. ALWAYS UPDATE:
i. Tobacco
ii. Recreational drugs
iii. Alcohol
iv. Sexual activity and precautions.
5b. If not in the chart:
i. Educational level
ii. Employment
iii. Home Environment
6. Review of Systems (ROS): MAX of 13 Questions (yes or no questions). A system above and below.
Constitutional Hematology/Lymphatic
Cardiac Immunologic:/Allergies
Endocrine Integumentary
ENMT Musculoskeletal
Eyes Neurological
Gastrointestinal Psychiatric
Genitourinary Respiratory
a. ROS: All body systems: START HERE. Very broad questions that are specific.
i. Depending on what they say, go to the specific body system.
7. PHYSICAL EXAM: Document Key Findings to the right. TAKE NOTES UNDER ASSESSMENT.
1. Vital Signs:
a. Pulse: Count for 30 seconds and multiple by 2.
b. Blood Pressure: Pump up to wear the pulse was and add 30 to that….
2. INSPECT (Look):
a. LOOK AT FINDINGS. WHAT SHOULD WE LOOK AT?
i. Example: Mouth and pharynx.
ii. Look at the rise and fall of the chest.
3. AUSCULTATE (Listen):
a. ALWAYS DO HEART, LUNG, AND ABDOMEN.
4. PALPATE:
a. Lymph nodes – from key findings.
8. Most Significant Active Problem (MSAP): Chose the MSAP.
a. Then with the other symptoms chose if they are related, unrelated or unknown.
b. READ the feedback, that will help with differential diagnosis.
9. Write your problem statement. The problem statement in 150 words or less. This is the synopsis.
“This is an 18-year-old male college student with a history of childhood asthma who presents with acute
onset of a non-productive cough, sore throat, fatigue, myalgias and headache for 4 days. He reports a sick
contact and has not had an annual flu vaccination or Covid booster. Physical examination reveals a
temperature of 101, tachycardia, erythematous pharynx and anterior cervical lymphadenopathy, but
negative for adventitious breath sounds and hepatosplenomegaly.”
10. Build your Differential: scroll down and pick your differentials.
11. Rank your diagnosis:
a. Lead
b. Must not miss.
12. Order Tests:
a. Interpret tests.
13. Chose final diagnosis.
14. SOAP Note: May not be required to do. Hit proceed. Read Plan feedback.
15. Read and download PDF Feedback!

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