NR 511 Week 2 iHuman Virtual Patient Encounter Attempt 2484649 - Gemma Jones
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History Notecard by Jessica Rhyan on case Gemma Jones 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: 2484649 Report generated on 9/10/2022, 8:19:32 PM America/Denver Management Plan by Jessica Rhyan on case Gemma Jones Diagnostic tests - no diagnostic tests needed. Could check IgM for acute illness, but not necessary (Bıçakçı et al., 2017). Medications - According to Epocrates: OTC Tylenol Suspension 5mL PO every 4-6 hours as needed for fever OTC Children's Advil suspension 5mL PO every 6-8 hours as needed for fever Suggested consults/referrals - This is a clinically diagnosed, self-limited illness that can be treated symptomatically, this no referral is needed (Hollier, 2021, p. 227). Client education - The rash should resolve within 24 hours. Tylenol and ibuprofen can be alternated for fever reduction. Ensure your child is intaking fluid, making a normal amount of wet diapers, and produces tears if she cries. Allow for plenty of rest. Take all medications as manufacturer directed on the back of the box, do not exceed recommended dosage. Make sure you read all labels of other medications to not give combination medications that contain acetaminophen or ibuprofen. Do not give aspirin. May return to daycare as soon as possible, since the fever broke last night (Hollier, 2021, p. 227). Follow-up - none needed, follow-up as needed Resources Bıçakçı, Z., Arvas, M. H., Biçer, C., Akay, A., Üstebay, S., & Ülker Üstebay, D. (2017). Evaluation of roseola infantum cases in terms of demographic properties and laboratory values. Journal of Pediatric Infection, 11(2), 53–59. https://doi.org/10.5578/ced.201717 Epocrates. (2022). https://online.epocrates.com/drugs Hollier, A. (2021). In Clinical guidelines in primary care (p. 227). essay, Advanced Practice Education Associates. Attempt: 2484649 Report generated on 9/10/2022, 8:19:32 PM America/Denver Social History Category Data entered by Jessica Rhyan Social History Lives in an apartment with both parents Review of Systems Category Data entered by Jessica Rhyan General denies fever, weight change, and change in appetite Integumentary / Breast admits to rash on abdomen and upper and lower extremities HEENT / Neck admits to rhinorrhea and cough Cardiovascular denies fatigue, SOB Respiratory admits to cough, denies SOB, wheezing, sputum Gastrointestinal diaper stools about two per day Genitourinary urine diapers 4-5 per day Musculoskeletal denies change in strength and range of motion Allergic / Immunologic Endocrine Hematologic / Lymphatic denies Neurologic denies, no history of seizure Psychiatric Physical
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