wagner-ihumanWeek2

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School

Chamberlain College of Nursing *

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Course

NR511

Subject

Medicine

Date

Dec 6, 2023

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pdf

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6

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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 This study source was downloaded by 100000829415905 from CourseHero.com on 11-05-2023 08:20:15 GMT -06:00
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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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