Select a Case
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👤 Case 1: Arm Pain
Patient: Jessie Collier
Age: 30
Gender: Female
Chief Complaint: Arm Pain
Case Objectives:
Your established patient is here in clinic with a new issue. Please take a thorough history. After the encounter, write a progress note, paying special attention to making an assessment/diagnosis and coming up with a plan. You are encouraged to use medical resources such as UpToDate or ask your faculty/student leaders for guidance! -
👤 Case 2: Follow-Up Visit
Patient: Donna Adkins
Age: 54
Gender: Female
Chief Complaint: Follow-up Visit
Case Objectives:
Your established patient is here for a follow-up visit. Please take a thorough history. After the encounter, write a progress note. The assessment and plan will be different from the one in Case 1 which addressed an acute concern. For this note documenting a follow-up encounter, consider what headings you would use for the Plan section. Use the USPTF Guidelines and CDC Adult Immunization Vaccine Schedule to develop your plan for her health maintenance issues.
Previous lab tests: PFTs showed a FEV1/FVC ratio of 0.6 and an FEV1 of 75% of predicted. As part of your work-up for her fatigue, you ordered a CBC (complete blood count), thyroid function tests, and BMP (basic metabolic panel). Her hematocrit was 38 (normal) and the rest of her labs were normal.
On review of her medical records, you find that her last tetanus vaccine was 11 years ago. She has never received a pneumococcal vaccine. Her last mammogram was a year ago. She has never had a colonoscopy or Chest CT. -
👤 Case 3: Inpatient Surgical Rounds
Patient: Robin Powell
Age: 26
Gender: Female
Chief Complaint: Inpatient Surgical Rounds
Case Objectives:
Ms. Powell is a 26-year-old woman with history of scoliosis who was admitted to the hospital 2 days ago with severe right lower quadrant pain that was accompanied by fever, nausea without vomiting, and anorexia. She was diagnosed with appendicitis in the emergency department and taken to the operating room the same afternoon for a laparoscopic appendectomy. As the MS2, you are her primary caretaker with supervision provided by the surgical intern, senior resident, and attending physician. You first met her in the ED on this day right before her surgery and then went home for the day while Ms. Powell was in the OR.
Yesterday, you evaluated her again. The night after surgery she had difficulty sleeping due to pain. She was able to eat a clear liquid breakfast this morning. She has been urinating normally but has not a bowel movement. Yesterday, she ambulated in the hall with her nurse’s assistance. When you left the hospital yesterday, she reported 4/10 pain that was much improved compared to before her surgery.
Today is POD #2 (post-operative day) – Write a daily inpatient progress note including an assessment and plan. You are encouraged to use medical resources such as UpToDate or ask your faculty/student leaders for guidance!