NR 511 Week 2 iHuman Virtual Patient Encounter - Kecia Young.
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• Respiratory: no cough currently; recent hx of non-produc琀椀ve cough for 3 days with runny nose • Gastrointes琀椀nal: no vomi琀椀ng, changes in appe琀椀te, or stool in diapers; 2 stool diapers per day • Genitourinary: 4-5 wet diapers per day • Musculoskeletal/Structural: No weakness, no recent trauma • Neurologic: no changes, no history of seizures • Psychiatric: happy child • Endocrine: no recent hx of uninten琀椀onal weight gain or loss despite normal appe琀椀te • Hematologic/Lympha琀椀c: no history of anemia • Allergic/Immunologic: UTD for immuniza琀椀ons un琀椀l 18 months Physical Exam Cogni琀椀ve: A&Ox4 General: HEENT/Neck: Head - Eyes: conjunc琀椀vae pink, no discharge; sclerae anicteric; orbital area without edema, redness, tenderness, or lesions Ears: EAC no discharge; TM non-injected, pinkish-grey, no discharge or purulence, landmarks visible, normal mobility with insu昀툀a琀椀on Nose: clear, no visible drainage Mouth: Neck: CV: normal heart sounds Chest/Respiratory: normal breath sounds GI: no pain, tenderness, masses, guarding Genitourinary/Rectal: not assessed Musculoskeletal/Structural: extremi琀椀es demonstrate no swelling or deformi琀椀es Neurological: appropriate for age Skin: warm and dry; maculopapular pink rash on abdomen and extremi琀椀es; normal skin turgor Lympha琀椀c: no pathologically enlarged lymph nodes in cervical, supraclavicular, axillary, or inguinal chains Psychiatric: appropriate for circumstances MANAGEMENT PLAN: • Diagnos琀椀c Tes琀椀ng: no diagnos琀椀cs necessary; symptoms alone support diagnosis • Medica琀椀ons/Treatment: none • Consults/Referrals: none • Suppor琀椀ve Care: maintain rest and hydra琀椀on • Pa琀椀ent Educa琀椀on: rash will resolve in a few days and should not cause scarring o Make sure to maintain good hand hygiene a昀琀er handling respiratory secre琀椀ons • Follow Up: none needed unless symptoms change o Con琀椀nue with well-child checkup visits REFLECTION: Re昀氀 ec琀椀on: Address the following ques琀椀ons:
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