Week 10 Assignment 1: iHuman Case Study
Overview
Case studies and simulations are excellent ways to practice critical thinking and
problem solving in patient care in a safe space. These case-based assignments
are designed to provide you with an opportunity to practice applying the
theoretical knowledge you have acquired in a real-life scenario. Use this
assignment to apply all the best practices that you have learned and be as
thorough and detailed as you can.
In this course, we will be using an interactive simulation tool called iHuman to
provide you with exposure to case study information. Through iHuman, you will
have the opportunity to interact with a simulated patient to collect and analyze
data much in the same way you would in real life. After collecting that data, you
will use the iHuman platform to diagnose and develop a treatment plan. After
completing the iHuman case, you will prepare a SOAP note to summarize and
provide an overview of the simulated clinical experience. The SOAP note is a good
tool to use in your practice, as it covers the areas of documentation that are
considered vital in order to achieve the goals of treatment. You will be using SOAP
notes (or something similar) frequently in your practice.
Instructions
1. Complete the iHuman case study assigned for the week. You will be
working in the iHuman platform to complete the case. Follow the directions
on logging in and navigating in iHuman. You will need to input your first
and last name and email address to access the recording. Refer back to
the iHuman Orientation for complete instructions on navigating in iHuman.
a. When working in iHuman, practice as if this were a real patient. For
example, the platform allows you to ask many questions when
taking a history. However, in reality, you will likely be limited in time.
Practice setting yourself a time limit (minimum 1 hour) and work on
being efficient in your clinical interview. While there is time for
empathy, you do not want to distract from good clinical
investigation.
2. In iHuman, review the specific instructions for the appropriate case. These
instructions will help you understand the expectations of each case, as
they may differ.
3. Once you have completed all the steps in iHuman, complete a SOAP Note
(Word) for the patient you worked with. (Note: The template is meant to be
a guide. You can change the formatting of your SOAP note if the table style
does not work for you. Additionally, you can copy and paste what you have
written in iHuman into your SOAP note if the content is appropriate.)
a. Your SOAP note should be no more than five pages long.
b. Use academic sources, cited in APA format, to support your rationale
in your Assessment and Plan.
2. Upload a copy of your simulation/iHuman log and the time spent in the
simulation along with your SOAP note for this assignment.
3. While items in iHuman may be auto-marked, your grade for this
assignment is not based on how you perform within iHuman. The iHuman
platform is merely an opportunity for you to interact with a simulated
patient and gather data.
4. If you require technical support with the iHuman platform, use the iHuman
Help Center to contact iHuman Technical Support directly. Technical
support includes a malfunction of the platform; they will not be able to
help with issues involving content!
This is the information I gather from the I human
Weight: 122 lbs (55.5 kg); BMI 20.0 Height: 5’5” (1658cm)
Vital Signs: Temp: 98.2 (oral)BP: 116/72 mmHg left arm, 116/72 mmHg right arm sitting
position HR: 72 bpm, regular rhythm RR: 18 bpm; regular effort and unlabored SpO2: 99%n
room air Pain: 0 on a 0-10 scale
General appearance:
Skin: Warm, dry
Mouth: Charcoal stained due to gastric lavage
HEENT: Normocephalic, atraumatic, facial features symmetric, PERRLA
Neck: Thyroid WNL for size and consistency. No nodules. No cervical mass
Chest/Lung: Thorax atraumatic. Normal respiratory rate and effort. No use of accessory
muscles. LSC to auscultation bilaterally.
Abdomen: Flat, symmetric, non-distented, +BS x 4
Cardiovascular: Normal S1 and S2, no S3. No rubs, murmurs, or gallops. No palpable thrill
Neurologic: A+O x 4, CN I-XII grossly intact. Slight psychomotor retardation
Visual: Occasionally teary, fair eye contact, sitting up in a chair, slight psychomotor retardation
Auditory: Soft volume, some speech latency, reduced intonation
Odor: Faint odor of alcohol
PMH:
Obstetric/gynecologic: G0P0
Immunization Status: Up to date.
Patient was brought in to ER by her boyfriend
Patient is at the Emergency room
Me: What brought you here?
I’m really embarrassed right now, ok? I don’t remember exactly what happened, but basically
my friends and I smoked a bunch of weed last night and I went out for a few drinks—like
maybe 2 beers and 3 hard drinks. I came home and got into it with my it with my ex-boyfriend. I
remember being really irritated and angry with him after he told me head gone out with my
friend. I already had a headache, I was feeling overwhelmed. I couldn’t take any more grief
from him, so I just wanted to go to sleep. I took 4 acetaminophen with diphenhydramine, but it
didn’t work, so I took 2 (1 mg) tablet of Alprazolam, too. I don’t really know what happened;
after that but the emergency room doctor told me my boyfriend got worried because he
couldn’t wake me up to move me from the couch to the bedroom.
Pt reports she has been feeling anxious for about 3 weeks, reports she feels anxious about
having to find a new place where to live, reports her anxiety is like getting wound up about
what if’s, like not knowing how something’s going to turn out. Pt reports she recently broke up
with her ex-boyfriend about 3 weeks ago, reports they live together and they have constantly
having arguments, reports “but it wasn’t until last night when he told me that he was spending
time with one of my good friends” and is now looking for a place to live. Reports things have
gone bad emotionally
Just recently broke up with boyfriend. Reports have support of two closed friends. She also
reports she is very closed with her two sisters.
Reports difficulty falling asleep, states after she fall asleep, she sleeps for about 9 hours. Pt
reports headaches often, states she gets them frequently, reports “It just stress”. She reports
her muscles feels tight and was told by her PCP they are due to muscle tension headaches.
Patient reports she works as a “Art-gallery modulator” 5 hours a week. Patient also reports she
that school and work causes her a lot of stress, reports difficulty focusing with both, reports
Reports feeling well about life. Patient reports she likes watching movies with her friends,
states “it’s her stress reduction program” . Patient also reports she attends a community
college.
Denies past mental health problems, denies seen a psychiatric or therapist in the past. States
she had a bad break up in high school and her PCP told her she was depressed but didn’t think
she needed anything else for it. Pt reports when she was a kid her teacher thought I might have
ADHD but never got treated or tested for that either. Patient also reports before her break up
she sometimes gets stressed about the usual stuff in my life but never like this.
Any other symptoms of concern?
I guess every one is wondering if I freaked out and was trying to kill myself. I absolutely not. I
was tired and had a headache and couldn’t’ fight it anymore with him, you know, my ex-
bofrient. I just wanted to go to bed and apparently you can’t mix alcohol, weed, and sleep
medicines. That’s what ER doctor told me. I just wanted to go to sleep, I wasn’t thinking it might
kill me.
Denies weight loss
Denies SI, HI, AVH/HA
Family history: Father is an alcoholic, never gotten help for it. Mother struggles with
depression, reports mom takes antidepressant, Paxil and Xanax.
Denies children
Unaware of grandparent’s health
PMH: Diagnosed 3 years ago with hypothyroidism. Taking Synthroid 75 mcg and also birth
control pills
For sleep she sometimes take wine or Xanax 1 mg for sleep
Tylenol OTC
Drinks alcohol 2-3 beers on the night, once or twice during the week and usually on the
weekend 1 or both nights, and almost always with my girlfriends. We sometimes drink wine or
hard liquor or both but that’s pretty rare. We like to get a buzz on and go out dancing. I might
have a few more drinks on the weekend when I go out with my friends.
Mood : embarrance
AffectL dysphoric, slightly guarded, congruent
Allergic: Penicillin (gets Hives)
Pt has 2 sisters that lives in town, states very supportive of each other, states she grew up in a
really strict household with her parents and 1 brother. Reports mom was very religious catholic.
I had to move to Florida and live with my uncle after high school—-just to get away from family
and figure who I am. But I’ve been back in Illinois now for the past 3 years. Don’t get me wrong,
my parents weren’t abusive, they just were very strict and didn’t allow us to do anything.
Pt reports appetite change since her brake up with her boyfriend but her weight has not
changed
Up to date with immunization
AOx4, she is in the emergency room
Childhood illness: cough, cold, tommy aches, nothing major
Denies history of hospitalization
Denies depression
Screening tools:
PHQ-9 =7
GAD= 9
AUDIT = 9
Laboratory and Diagnostic Studies Blood Alcohol concentration: (164mg/dL) Normal
Acetaminophen (paracentamol) level, blood: (11 Ug/mL)
Normal Complete blood count (CBC) with different: Normal Comprehensive metabolic panel
(CMP): Abnormal levels; hyperchloremia 104mmol/L (ref. range (95-102mmol/L); hypokalemia
3.3mmol/L (ref. range 3.5-5.1mmol/L)
Thyroid Function tests (TFT): Normal TSH and FT4
Drug toxicology testing, urine: Positive for benzodiazepine use
Human Chorionic gonadotropin (hCG), urine: Negative
Salicylate (ASA) level: Normal
Differential diagnoses:
-Acute stress disorder
-Generalized anxiety disorder
-Adjustment disorder with anxiety and conduct disorder
-depression due to alcohol
-major depression disorder
-normative stress reaction
-hypothyroidism
-separation anxiety disorder
Diagnosis:
Adjustment disorder with anxiety and conduct disturbance
Poisoning (ingestion) by alcohol, benzo, acetaminophen, dip….
This is my professor feedback from the first I human I posted:
You did an excellent job writing this first SOAP note and I hope you continue to
improve as the semester progresses. This patient has difficulty adjusting to her
new school environment
In future assignments, you should provide your final/working diagnosis and
possible diagnoses with rationales/citations. All diagnoses must have DSM-V and
ICD-10 codes
The clinical impression should be in your own words. It is the summary of what
you think/conclude based on your assessment
If you determine that a client qualifies for a specific diagnosis, you should be able
to identify the symptoms as indicated in the HPI. Your differentials may also
include rule out (R/O), meaning that you believe that a client has some elements
of a particular diagnosis based on DSM-V symptoms but not enough to qualify
for such a diagnosis; that is why you are ruling them out.
I understand that this is your first SOAP note. It takes time and effort to develop
expertise in writing a good SOAP note, please check the templates sent at the
beginning of the semester for additional help. Good effort!