NR 509 Week 3 i-Human Virtual Patient Encounter Attempt 3481164 - Amanda Wheaton
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History Notecard by Briayanna Nordwick on case Amanda Wheaton 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 =sore Sx Sx = Sx Sx HPI throat =headache fever =swollen = glands Onset 2 days ago 2 days ago 2 days 2 days ago ago Location neck Duration 2 days intermittent 2 days 2 days 2 days Characteristics "ice pick" "dull" Aggravating trouble swallowing Relieving ice cream, Tylenol Timing / Tylenol Tylenol Tylenol Treatments Severity "11" mild Attempt: 3481164 Report generated on 3/23/2025, 3:19:49 PM America/Chicago Management Plan by Briayanna Nordwick on case Amanda Wheaton Medications Amoxicillin 500mg PO BID x7 days Acetaminophen 650mg to 1000mg PO q4-6 hrs PRN for fever/pain Ibuprofen 600mg-800mg PO q4-6hrs PRN for fever/pain Hydration for supportive management and fever, gargle warm salt water for sore throat Consult/Referrals None needed at this time. May consult ENT if sore throat continues after treatment Education Although you tested negative for strep, your symptoms may still indicate strep virus, and you will be treated as such. Take all antibiotics even when you're feeling better. This reduces antibiotic resistance May provide school note remain at home until symptoms resolve Call PCP or go to ER if you develop a rash or shortness of breath after starting antibiotics Proper hand hygiene to prevent spread of infection Follow up Return to PCP or ER if you are unable to swallow, eat or drink, develop a hoarse voice, difficulty breathing, neck stiffness or excessive drooling. Attempt: 3481164 Report generated on 3/23/2025, 3:19:49 PM America/Chicago Review of Systems Category Data entered by Briayanna Nordwick General pt reports not feeling well x2 days. sudden onset sore throat w/intermittent mild headache, chills, fever Integumentary / Breast skin appears normal, denies issues HEENT / Neck sore throat, swollen glands, headache Cardiovascular denies chest pain Respiratory denies cough, SOB, wheezing Gastrointestinal denies n/v/abd pain Genitourinary denies issues w/urination Musculoskeletal denies musculoskeletal pain/issues Allergic / Immunologic denies allergies to medications Endocrine not assessed at this time Hematologic / Lymphatic not assessed at this time Neurologic denies issues Psychiatric not assessed at this time Physical Exams Category Data entered by Briayanna Nordwick General well-looking appearance Skin skin appears well, good skin turgor, no rashes or lesions noted HEENT / Neck prominent exudates bilaterally, tonsils enlarged, erythematous posterior pharynx Cardiovascular within normal limits, pulse 94 Chest / Respiratory within normal limits, lung sounds are clear, respirations 15 Abdomen within normal limits, spleen not palpable, liver palpated at 8 cm, bowel sounds normoactive
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