NR 509 Week 3 i-Human Virtual Patient Encounter Attempt 3413195 - Jenna James
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History Notecard by Lauren Stafford on case Jenna James 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. Sx HPI Sx = sore Sx =swollen Sx throat =headache lymph =fev nodes Onset 2 days ago Location throat head Duration ongoing intermittment Characteristics like an ice pick dull Aggravating swallowing Relieving acetaminophen Timing / Treatments Severity very severe mild Attempt: 3413195 Report generated on 1/24/2025, 2:43:10 PM America/Chicago Management Plan by Lauren Stafford on case Jenna James Diagnostic tests: 1) Group A strep antigen-negative 2) Influenza PCR-negative 3) Covid-19 PCR-negative 4) Throat culture-pending results The most common cause of pharyngitis is infection by Group A streptococcus (Mustafa & Ghaffari, 2020). Therefore, a throat culture confirming a diagnosis would be helpful when formulating a treatment plan. Medications/Treatment: 1) Amoxicillin 50mg/kg for 10 days (CDC, 2024) 2) Tylenol 500 mg every 4-6 hours for pain 3) Ibuprofen 400 mg every 6 hours for your fever, alternate therapy with tylenol Consults/Referrals: None needed at this time. If the throat culture comes back with a different strain, we may need to include infectious disease to modify your antibiotic treatment plan. Client Education: It's important to perform good hygiene. If your symptoms persist you should stay home from school to prevent spread of the disease. Complete the entirety of your antibiotic course to ensure full therapeutic effects (CDC, 2024). Follow Up: If symptoms persist after 48 hours please return to our clinic for further evaluation (i.e. severe sore throat, difficulty swallowing, fever, etc.) References Centers for Disease Control and Prevention. (2024, April 23). Clinical Guidance for Group A Streptococcal Pharyngitis. Group a Strep Infection. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html Mustafa, Z., & Ghaffari, M. (2020). Diagnostic Methods, Clinical Guidelines, and Antibiotic Treatment for Group A Streptococcal Pharyngitis: A Narrative Review. Frontiers in Cellular and Infection Microbiology, 10(10). https://doi.org/10.3389/fcimb.2020.563627 Attempt: 3413195 Report generated on 1/24/2025, 2:43:10 PM America/Chicago Social History Category Data entered by Lauren Stafford Social History Occasional social drinker with her law school friends, 2-3 a week. Denies tobacco or recreational drug use. Review of Systems Category Data entered by Lauren Stafford General Denies weight loss or fatigue Integumentary / Breast Denies rash, ecchymosis or petechiae HEENT / Neck Patient has a sore throat and swollen lymph nodes. Her lymph nodes are tender to the touch and she describes her throat like there is an "ice pick in there". Denies rhinorrhea, congestion, or congjunctivitis Cardiovascular Denies chest pain or palpitations Respiratory Denies SOB or wheezing Gastrointestinal Denies vomiting, diarrhea, or constipation
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