Highlights
Task:
Putting it all Together
As discussed, obtaining an accurate history is the critical first step in determining the etiology of a patient's problem. A large percentage of the time, you will be able to make a diagnosis based on the history alone. The value of the history, of course, will depend on your ability to elicit relevant information. Your sense of what constitutes important data will grow exponentially in the coming years as you gain a greater understanding of the pathophysiology of disease through increased exposure to patients and illness. Now we take it to a more refined approach by eliciting a history of present illness (HPI). The patient's reason for presenting to the clinician is usually referred to as the "Chief Concern." You might see the HPI indicated in an acronym such as OLDCARTS, LOCATES, or OPQRST formats for memorization. Pertinent negatives are also an important aspect of a good HPI. This assignment is intended to allow you to show evidence of achievement of:
CLO 1: Obtains a relevant health history for patients of all ages and in all phases of the individual and family life cycle using collateral information, as needed.
CLO 3: Integrates information elicited in family and personal health histories and physical exam findings to identify appropriate further assessment and diagnostic procedures.
Requirements
Danny Rivera is a pediatric patient presenting with a cough. In this Shadow Health assignment, you will conduct a focused exam and document your findings, focusing on the history of present illness. Consider how you communicate with a pediatric patient to obtain a history of present illness (HPI). Expect to spend approximately 1 hour and 15 minutes on this assignment, so allow plenty of time before the due time.
To complete the Assignment, access the Shadow Health program and click on Focused Exam Cough – Danny Rivera. You do not need to complete the full simulation. Instead, you will complete and submit an SAP note (omitting the objective section of the SOAP note). The intent of the Assignment is to focus on the HPI.
Submit by 11 p.m. Sunday of Week 3.
View Grading Rubric
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