NR 511 Week 2 iHuman Virtual Patient Encounter Attempt 2551363 - Kecia Young

lOMoARcPSD|1709022 History Notecard by Amber Quinn on case Kecia Young 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: 2551363 Report generated on 11/5/2022, 5:25:14 PM America/Denver lOMoARcPSD|1709022 Management Plan by Amber Quinn on case Kecia Young Diagnostic Tests None Medications Acetaminophen: 10-15 mg/kg/dose PO q4-6h as needed; Max: 75 mg/kg/day up to 1 g/4h and 4 g/day Ibuprofen: 5-10 mg/kg/dose PO q6-8h as needed; Max: 40 mg/kg/day; Info: use lower dose for fever 102.5 F; use shortest effective tx duration You may obtain these medications over-the-counter. Consults/Referrals None needed at this time Client Education Ensure adequate rest and hydration, the child should continue to have 4-5 wet diapers daily; if decreases, contact the healthcare provider. The rash will start to fade and go away on its own, it should not leave any scars. Avoid scratching the rash. Scratching can cause an unwanted opening of the skin, which places the patient at risk of bacteria entering the body. Acetaminophen and Ibuprofen weight-based dosing chart will be provided to the mother. Both medications can be given for fever or pain/discomfort. Alternate medications every 4-6 hours. Check the child's temperature before administering medication. Ibuprofen can cause GI upset, give with food if this occurs. If a fever of 100.4 or greater returns, persists, or does not improve despite medication management, contact the office for further direction. Uncontrolled fevers can potentially cause febrile seizures. If any seizure-like activity occurs or if your child becomes lethargic, please go to the nearest emergency department. The child may return to daycare when fever free. Follow-up No follow-up is needed unless worsening symptoms. The patient should return for a two-year well-child once the child is feeling better. References Hollier, A. (2021). Clinical practice guidelines in primary care. Advanced Practice Education Associates. Epocrates. (n.d.-a). Acetaminophen. https://online.epocrates.com/drugs/30602/acetaminophen/Peds-Dosing Epocrates. (n.d.-b). Ibuprofen. https://online.epocrates.com/drugs/23302/ibuprofen/Peds-Dosing Attempt: 2551363 Report generated on 11/5/2022, 5:25:14 PM America/Denver lOMoARcPSD|1709022 Social History Category Data entered by Amber Quinn Social History Attends daycare Review of Systems Category Data entered by Amber Quinn General Alert, active Integumentary / Breast HEENT / Neck Runny nose Cardiovascular No history of murmurs or irregular heartbeats. Respiratory Non-productive cough, no wheezing or shortness of breath Gastrointestinal Denies vomiting, diarrhea, or constipation, having about 2 stool diapers daily. Genitourinary No history of UTI's wears diapers, and has about 4-5 wet diapers daily Musculoskeletal