NR 509 Week 2 i-Human Virtual Patient Encounter Practice Case and Self-Assessment Attempt 3392878 - Marvin Webster
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History Notecard by Taylor Morris on case Marvin Webster 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: 3392878 Report generated on 1/12/2025, 1:48:38 PM America/New_York Management Plan by Taylor Morris on case Marvin Webster Subjective Chief Complaint: "I feel awful, Iām exhausted. I have a cough and body aches." HPI: MW is an 18-year-old male college student presenting with a 4-day history of acute onset cough, sore throat, headache, fatigue, and body aches. He reports recent exposure to a sick contact and has not received the annual influenza vaccine. He denies nausea, vomiting, diarrhea, or shortness of breath. Past Medical History: Childhood asthma, no recent exacerbations. Medications: Ibuprofen as needed. Allergies: No known allergies (NKA). Social History: Non-smoker, denies alcohol and illicit drug use. Family History: Father (57) healthy; mother (58) with hypertension. ROS: General: Reports fatigue. HEENT: Reports headache responsive to ibuprofen and sore throat. Denies sinus problems, runny nose, or visual disturbances. CV: Denies chest pain, palpitations, or shortness of breath. Respiratory: Reports a dry, non-productive cough. Denies wheezing or dyspnea. GI: Denies nausea, vomiting, or changes in bowel habits. Other Systems: No significant findings reported. Objective Vital Signs: Temp: 101Ā°F, HR: 108 bpm, RR: 16 bpm, BP: WNL. General: Alert, oriented, no acute distress. HEENT: Erythematous pharynx, bilateral anterior cervical lymphadenopathy (0.8-1 cm). CV: Tachycardic, regular rhythm, no murmurs, rubs, or gallops. Respiratory: Clear lung sounds bilaterally, no adventitious sounds. Dry, non-productive cough noted. Abdomen: Soft, non-tender, active bowel sounds. Skin: No diaphoresis or flushing. Lymphatic: Bilateral cervical lymphadenopathy. Assessment Primary Diagnosis: Viral upper respiratory infection, likely influenza. Key findings: Fever (101Ā°F), tachycardia, sore throat with erythematous pharynx, dry cough, myalgias, fatigue, anterior cervical lymphadenopathy, and history of sick contact. Plan Diagnostics: No additional testing is needed. Influenza PCR and rapid diagnostic testing confirmed influenza. Medications: Acetaminophen: 325 mg, 1-2 tablets PO every 4-6 hours as needed for fever, headache, and body aches (max 10 tablets/day). Dextromethorphan/Guaifenesin: 20 mg/400 mg PO every 4 hours as needed for cough (max 120 mg dextromethorphan/day, 2400 mg guaifenesin/day). Supportive Care: Increase fluid intake to prevent dehydration. Rest and avoid physical exertion. Patient Education: Practice cough hygiene (cover nose/mouth, wash hands frequently). Disinfect commonly touched surfaces. Avoid close contact with others and stay home until fever-free for 24 hours without fever-reducing medications. Discuss the importance of receiving an
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