Dr. Smith enters the room, greets Melissa and together they review her initial assessment, including her fatigue, weight loss and sore throat. Dr. Smith performs a physical exam and notices that Melissa’s lymph nodes are swollen and that she has a slight rash (which is added into Melissa’s EHR). Dr. Smith orders three tests — two tests require swabbing Melissa’s throat and the other is a blood sample.

  1. Review Melissa’s EHR: What information is NOT included on her EHR?
    1. Radiology & Diagnostic Imaging
    2. Vital Signs
    3. Signs & Symptoms
    4. Laboratory Results

  2. Discussion Question: What do you think is wrong with Melissa?