NOTES FROM i-HUMAN ASSESSMENT:
1) Observations: warm and sweaty
2) Name stated correctly
3) Location stated correctly (In the ED)
4) Time stated correctly (14:30)
5) How can I help you today? I have been feeling sic
...
NOTES FROM i-HUMAN ASSESSMENT:
1) Observations: warm and sweaty
2) Name stated correctly
3) Location stated correctly (In the ED)
4) Time stated correctly (14:30)
5) How can I help you today? I have been feeling sick, but I got scared when I woke up
this morning unable to move the left side of my face. See how droopy it is. I've never
had anything like this in my face before. What could cause this?
6) Do you have other symptoms or concerns we should discuss? I have also had a fever
and chills. I just assumed it was some kind of bug and kept pushing through it. At the
beginning of these symptoms I saw a doctor near our work site and was given a five
day course of antibiotic. It didn't do much. Oh, I also have had some new skin stuff.
Maybe a rash but they are flat and red. Really strange. I get cuts and scrapes a lot at
work but these things are different.
7) Do you have any pain in your chest? No
8) Do you experience chest pain discomfort or pressure; pain, pressure, dizziness with
exertion or getting angry; palpitations; decrease exercise tolerance; blue/cold
fingers and toes? No, not that stuff.
9) Can you tell me about any current or past medical problems you have had? I have
high blood pressure and plaque psoriasis. Other than that I am or was healthy until
recently.
10) Any previous medical, surgeries, or dental procedures? No
11) Do you have heart disease and/or have you ever had a heart attack? No
12) Are you taking any prescription medications? Yes. I take atenolol and chlorthalidone
for my blood pressure.
13) Have you recently taken any antibiotics? Yes
14) Are you taking any over the counter or herbal medications? Recently I have been
taking ibuprofen. Oh yeah, I also took him multivitamin.
15) When was your last physical? I do not remember
16) Do you have any problems with fatigue, difficulty sleeping, unintentional weight
loss or gain, fevers, or night sweats? Well maybe, I have been a bit more wiped out
after work than usual. Did I tell you about some of the other stuff?
17) Do you have any allergies? No
18) Are your immunizations up to date? I think so.
19) Do you have any sensation of a” pounding heart” in your chest? Uh… no
20) Do you have any problems with itchy scalp, skin changes, molds, thinning hair, or
brittle nails? Yes, some new skin stuff. Didn't answer about that?
21) Do you have new headaches that you have not experienced previously? No
22) Do you have any pain anywhere? If so, where? No
23) Have you ever been hospitalized? No
24) Have you had any significant traumatic injuries or accidents? No
25) What childhood illnesses have you had? The usual coughs, calls, and some eggs.
Nothing remarkable.
26) Do you drink alcohol? If so, what do you drink and how many drinks per day? Yes. I
have maybe a beer at night. Most nights. Nothing much more than that.
27) Do you ever have withdrawal symptoms if you do not drink for their two? Feeling
shaky or jittery? No
28) Do you know or have you ever smoked or chewed tobacco? Yes, I smoke. About a
packet day for 20 years.
29) Do you use any recreational drugs? If so, what? No. I never got into that stuff. Never
would.
30) Do you have parents, children, or their family members or individuals living at
home? Do you really need to know that?
31) Are you sexually active? Yes. What does that have to do with this?
32) Have you ever had any sexually transmitted infections? No
33) Can you tell me about your diet? What do you normally eat? Seems normal to me.
Hint 1 of 5:
You have asked 12 key questions. 30 key questions remain.
You need:
- 11 more in Chief Complaint Sx/Sx Characteristics
- 4 more in Associated Symptoms
- 1 more in PMH
- 5 more in SH
- 1 more in FH
- 8 more in ROS
Your current Hx efficiency is 11%.
34) Do you drink caffeinated beverages or eat chocolate? No
35) Tell me about daily exercise or sports you play. I don't play sports.
36) Do you have HIV? No
37) Have you had or been exposed to song with appetites? No
38) Do you experience shortness of breath, wasting, difficulty catching your breath,
chronic cough, or sputum production? No, nothing you. I have a morning cough but
that has not changed.
39) Are you coughing any sputum? No
40) Do you awaken at night coughing? Uh… No
41) Do you have difficulty breathing? No
42) Do you have any problems with fatigue, difficulty sleeping, unintentional weight
loss or gain, fevers, or night sweats? Well maybe, I have been a bit more wiped out
after work than usual. Did I tell you about some of the other stuff?
43) Do you have night sweat? Not since I take ibuprofen before bed.
44) Do you have a problem with fatigue/tiredness? No
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