wagner-ihumanWeek2
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School
Chamberlain College of Nursing *
*We aren’t endorsed by this school
Course
NR511
Subject
Medicine
Date
Dec 6, 2023
Type
Pages
6
Uploaded by BailiffFangStork11
Report generated on 11/5/2022, 1:01:54 PM America/Denver
Performance Overview for Ashley Wagner on case Kecia Young
The following table summarizes your performance on each section of the case, whether you completed
that section or not.
Time spent: 1hr 5min 59sec
Status: Submitted
Case Section
Status
Your
Score
Time spent
Performance Details
Total Score
88%
History
Done
88%
18min
35sec
120 questions asked, 14 correct, 2 missed relative to the case's list
Physical exams
Done
94%
7min 26sec
53 exams performed, 12 correct, 1 partially correct, 0 missed relative
to the case's list
Key findings
organization
Done
25sec
5 findings listed; 5 listed by the case
Problem
statement
Done
2min 35sec
80 words long; the case's was 76 words
Differentials
Done
20%
3min 13sec
2 items in the DDx, 1 correct, 4 missed relative to the case's list
Differentials
ranking
Done
100%
(lead/alt
score)
80%
(must
not miss
score)
36sec
Tests
Done
100%
44sec
0 tests ordered, 0 correct, 0 missed relative to the case's list
Diagnosis
Done
100%
5sec
Management
plan
Done
23min
41sec
127 words long; the case's was 37 words
Attempt: 2559134
This study source was downloaded by 100000829415905 from CourseHero.com on 11-05-2023 08:20:15 GMT -06:00
Report generated on 11/5/2022, 1:01:54 PM America/Denver
History Notecard by Ashley Wagner on case Kecia Young
Use this worksheet to organize your thoughts before developing a differential diagnosis list.
1.
Indicate key symptoms (
Sx
) you have identified from the history. Start with the patient's reason(s) for the encounter
and add additional symptoms obtained from further questioning.
2.
Characterize the attributes of each symptom using
"OLDCARTS"
. Capture the details in the appropriate column and
row.
3.
Review your findings and consider possible diagnoses that may correlate with these symptoms. (Remember to consider
the patient's age and risk factors.) Use your ideas to help guide your physical examination in the next section of the
case.
HPI
Sx =
Sx =
Sx =
Sx =
Sx =
Sx =
Onset
Location
Duration
Characteristics
Aggravating
Relieving
Timing /
Treatments
Severity
Attempt: 2559134
This study source was downloaded by 100000829415905 from CourseHero.com on 11-05-2023 08:20:15 GMT -06:00
Report generated on 11/5/2022, 1:01:54 PM America/Denver
Problem Statement by Ashley Wagner on case Kecia Young
Kecia Young is an overall healthy 2-year-old female with no significant medical issues. She lives with her mother and father who
are overall healthy, in an apartment and goes to daycare. Up to date on immunizations. Appears today with a rash appearing on
the abdomen and spreading to extremities. Did have a fever x3 days ago with a cough, runny nose, and irritability. Upon exam,
a rash was noted. Afebrile today. No runny nose or cough was noted upon assessment.
Attempt: 2559134
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Report generated on 11/5/2022, 1:01:54 PM America/Denver
Management Plan by Ashley Wagner on case Kecia Young
Diagnostic Testing: none needed
Medications/Treatments: Continue Tylenol as needed for fever, inflammation, or pain. otherwise typically resolves on its own.
Rest
Fluid encouragement
Referrals: none needed
Client education: Encourage rest and fluids, as fevers can cause dehydration.
Monitor fever. If the fever persists over 103 degrees, and cannot be brought down with medications, seek immediate care, as this
can cause seizures (Mayo Clinic).
The child is no longer considered contagious after they have been fever free for 24 hours. (Hopkins Medicine)
Encourage hand washing
Monitor for a decrease in wet or dirty diapers
Follow up: Routinely and as needed, or if symptoms do not resolve. If symptoms worsen (don't resolve after 3 days or fever
returns), seek immediate care.
Reference: Mayo Clinic and Hopkins Medicine
Hopkinsmedicine.org/health/conditions-and-diseases/roseola
Mayoclinic.org/diseases-conditions/roseola/diagnosis-treatment
Attempt: 2559134
This study source was downloaded by 100000829415905 from CourseHero.com on 11-05-2023 08:20:15 GMT -06:00
Electronic Health Record by Ashley Wagner on case Kecia Young
History of Present Illness
Category
Data entered by Ashley Wagner
Reason for Encounter
Rash on abdomen and arms
History of present illness
overall healthy 2 y.o.
Past Medical History
Category
Data entered by Ashley Wagner
Past Medical History
Hospitalizations / Surgeries
Medications
Category
Data entered by Ashley Wagner
Medications
Allergies
Category
Data entered by Ashley Wagner
Allergies
Preventive Health
Category
Data entered by Ashley Wagner
Preventive health
Family History
Category
Data entered by Ashley Wagner
Family History
Social History
Category
Data entered by Ashley Wagner
Social History
This study source was downloaded by 100000829415905 from CourseHero.com on 11-05-2023 08:20:15 GMT -06:00
Report generated on 11/5/2022, 1:01:54 PM America/Denver
Review of Systems
Category
Data entered by Ashley Wagner
General
Overall healthy appearing 2 year old female
Integumentary / Breast
positive for skin rash to abdomen and arms
HEENT / Neck
positive for runny nose
Cardiovascular
Negative
Respiratory
positive for cough
Gastrointestinal
Negative
Genitourinary
Negative
Musculoskeletal
Negative
Allergic / Immunologic
positive for skin rash to abdomen and arms, positive for fever
Endocrine
negative
Hematologic / Lymphatic
negative
Neurologic
positive for some irratability
Psychiatric
positive for irritibility
Physical Exams
Category
Data entered by Ashley Wagner
General
overall healthy appearing 2 year old female
Skin
maculopapular pink rash on abdomen and extremities
HEENT / Neck
negative
Cardiovascular
heart rate and rhythm regular
Chest / Respiratory
respiratory rate regular, unlabored
Abdomen
maculopapular pink rash
Genitourinary / Rectal
negative
Musculoskeletal / Osteopathic
Structural Examination
negative equal strengths and ROM bilaterally
Neurologic
alert, no irregularities
Psychiatric
negative
Lymphatic
negative
Attempt: 2559134
This study source was downloaded by 100000829415905 from CourseHero.com on 11-05-2023 08:20:15 GMT -06:00
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