NR 509 Week 3 iHuman Virtual Patient Encounter Attempt 3548756 - Rebecca Fields
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History Notecard by Cheryl Cruikshank on case Rebecca Fields 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: 3548756 Report generated on 5/19/2025, 10:57:00 AM America/Chicago Management Plan by Cheryl Cruikshank on case Rebecca Fields Diagnostic tests- Rapid Strep Antigen Detection Test (negative); Influenza PCR (negative); Rapid Influenza Diagnostic Test (negative); COVID-19 PCR (negative); throat culture (results pending). The rapid antigen test was negative. A throat culture is the gold standard for diagnosis and is more sensitive than rapid antigen testing (Schreiber, 2024). Medications/treatments- Take OTC medications to manage fever and pain. 1-2 tablets of OTC acetaminophen (325 mg) orally every 4-6 hours as needed for fever/pain. Do not exceed max dose of 4,000 mg/day (Prescribers’ Digital Reference, n.d.). Penicillin V 250mg 4 times or 500mg two times a day by mouth for 10 days (Schreiber, 2024). Consults/referrals- Consult an otolaryngologist if the client has severe dysphagia or dyspnea (Cash, 2024). Client education- The client is considered contagious until they have taken antibiotics for at least 2 days, the client should rest for the first two days, clients may begin to feel better after 24 hours of antibiotics, the client should always complete a full course of antibiotics, the client should use a new toothbrush after 2-3 days of antibiotic treatment but before completion of antibiotic treatment (Schreiber, 2024). Always cover your mouth and nose when coughing or sneezing. Practice good handwashing with soap and water or hand sanitizer. Avoid sharing beverages or eating after others. Gargle with warm salt water for sore throat. Follow-up- The client should return to the clinic if symptoms do not improve after 3-4 days of antibiotic treatment (Cahs, 2024). The client should seek immediate medical care if there is the development of difficulty breathing, you are unable to swallow, neck stiffness, tongue or neck swelling, or continuous fever (Schreiber, 2024). Resources Cash, J.C. (ed). (2024). Family practice guidelines (Sixth edition.). Springer Publishing Company, LLC. Prescribers’ Digital Reference. (n.d.). Acetaminophen - drug summary. https://www.pdr.net/drugsummary/Tylenol- 8HR-acetaminophen-2799 Schreiber, M.L. (2024). Strep throat: More than just a sore throat. Medsurg Nursing, 33(6), 302-304. https://doi.org/10.62116/MSJ.2024.33.6.302 Attempt: 3548756 Report generated on 5/19/2025, 10:57:00 AM America/Chicago Social History Category Data entered by Cheryl Cruikshank Social History Review of Systems Category Data entered by Cheryl Cruikshank General alert and oriented x 4, calm, reports fever and chills Integumentary / Breast
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