A 50-year-old male presented for a follow up after labs showed high cholesterol. His vitals, medical history of high cholesterol, family history of heart disease, and current medications were documented. He smokes half a pack daily and drinks 2 beers nightly. A 50-year-old male presented for a sore throat. His vitals, reason for visit of sharp throat pain for 3 days, medical history of high blood pressure and cholesterol, allergy to penicillin, social history of former smoking and current alcohol use, and medications were documented. A 57-year-old female presented with painful frequent urination for 3 days, consistent with a urinary tract infection. Her vitals, medical

1. Scenario 1: Patient is a 50 year old male who came in for a follow up from labs he had done two
weeks ago. He has been diagnosed with high cholesterol and needs his medication refilled. He
does not believe he is allergic to any medications. He currently takes Crestor but does not know
the dosage. He smokes about a half a pack of cigarettes each day, and drinks typically 2 beers
per night. He has a family history of stroke and heart attack. When his blood pressure was
taken today it was 140/85 with a pulse of 63. His height was measured at 72 inches and his
weight was 270 pounds.
Steps:
In the Vitals portion, enter in the height, weight, pulse, and blood pressure.
Next: Reason For Visit. Find follow up for laboratory assessment. Enter in the date of the blood
work.
Add in the additional reason for visit being medication refill.
Under patient history: Under past medical: enter in high cholesterol. Double click to add to the
current encounter. Under allergies, list any patient allergies. Under social history, using the
short list, add in the tobacco use, and the alcohol use. For medications search for Crestor and
select the correct dosage. For family history, enter in the heart attack and stroke.
Scenario 2: The patients is a 50 year old male who is here for bloodwork. He has a lab order
from his doctor. He is fasting today. He has high cholesterol and diabetes He does not smoke or
drink alcohol and is not allergic to any medications. He takes Pravastatin and Metformin. He has
a family history of diabetes. Today he weighed 237 pounds and was 70 inches tall. He had a
pulse of 78 and his blood pressure was 120/84.
Steps:
In vitals enter in height, weight, pulse, and blood pressure.
In reason for visit, include his lab exam. Include why he is requesting these labs, and who is
requesting them.
Under patient history include his diabetes and high cholesterol in past medical. For the allergies
enter in any allergies. For the social history enter in their alcohol use, and whether or not they
smoke. Add in medications that he takes. For his family history include any family history.
In Assessment & Plan add in the diagnoses that are on the lab order. Add in the lab orders. Find
when he will be following up. Include who the results will be faxed to.
Scenario 3:
The patient is a 62 year old female who has come in for a physical. She does not know when her
last pap smear was, but her last mammogram was in 2015 and it was normal. She is allergic to
streptomycin. She has been sleeping well and does not have any complaints. She has
depression and experiences heart palpitations. She takes Celexa and Metoprolol. She stopped
having periods around 7 years ago and has a family history of heart disease and colon cancer.
She has four kids and two were delivered through c-section. She does not smoke or drink
alcohol. She is requesting a pap-smear. Her blood pressure is 120/72 with a pulse of 60 beats
per minute. Her height was 64 inches today, and her weight was 130.0 lbs.

2. Steps:
Under vitals: enter in height, weight, blood pressure, pulse, and last menstrual period.
Under reason for visit: Find physical for female. Check how the patient is feeling and sleeping.
Enter in when her last pap smear was.
For history: enter in her depression and palpitations under past medical. Under allergies search
for streptomycin. Under social history enter in alcohol and tobacco use. For medications enter
in Celexa and Metoprolol. For family history search for heart disease and Cancer. Under
pregnancy and birth find the Pregnancies (Gravida), and enter in the number of pregnancies,
number of vaginal births, and the number of c-sections in the form G#, P#, C# A#. Enter in the
type of contraception that is being used. Under surgeries enter in the c-sections. Under health
maintenance enter the mammogram, date and whether it was normal or abnormal.
Scenario 4:
The patient is a 50 year old male who is coming in with a sore throat that started 3 days ago. He
describes the pain as sharp. He says that he took ibuprofen but it didn’t help. He has had a
fever and has ear pain. His child goes to daycare and had been sick last week. He is allergic to
penicillin. He has high blood pressure and high cholesterol. He drinks one or two beers a night.
He used to smoke but quit 12 years ago. He takes Simvastatin and Lisinopril. His weight today
was 234 lbs and he is 72 inches tall. He had a temperature of 100.5 F. His pulse was 72 and his
blood pressure is 150/90.
Steps:
Under vitals: enter in height, weight, blood pressure, pulse, and temperature.
Under reason for visit search for cold symptoms. In patient words write that the pain is sharp
and that the ibuprofen did not help. Under the cold symptoms check the symptoms he has
described. Check when the onset of his symptoms was. Check the correct exposure. Click on
associated symptoms and click on the ones that the patient has mentioned. Click on the risk
factors that the patient has mentioned.
Under history add hypertension and high cholesterol to past medical problems. For allergies
add in the patient’s allergies. Under social history click on the alcohol use and enter in the
patient’s alcohol use. For the tobacco use add in the patient’s former tobacco use. For
medications search for simvastatin and Lisinopril.
Scenario 5:
The patient is a 57 year old female who is complaining of a urinary tract infection. She is
complaining of painful and frequent urination. These started 3 days ago. She has had several
urinary tract infections in the past. She has a blood pressure of 160/92 with a pulse of 88. Her
last period was 10 years ago. She weight 185 pounds today and is 66 inches tall. She is allergic
to Cipro and has high blood pressure. She does not smoke and occasionally drinks wine. She
takes Lisinopril- Hydrochlorothiazide. She has a family history of high blood pressure.
Steps:
Under vitals: enter in height, weight, blood pressure, pulse, and last menstrual period.

3. Under reason for visit enter in urinary tract infection. Select the symptoms that she is
complaining about, the onset of the symptoms and if this has happened in the past.
Under History: enter in her history of high blood pressure. Search for her allergy to Cipro. Under
social history enter in her smoking and drinking habits. Under medications search for Lisinopril-
Hydrochlorothiazide. Under family history add in the high blood pressure.
Under assessment and plan: add in-house lab Urinary Analysis without microalbumin.