NR 511 Week 4 iHuman Case Study Performance Overview - Victoria Lewis

History Notecard by Sarah Wright on case Victoria Lewis 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: 3715524 Report generated on 11/1/2025, 5:09:11 PM America/Denver Management Plan by Sarah Wright on case Victoria Lewis Dx:Allergic Contact Dermatitis Diagnostic test: None Pharmacological: -Triamcinolone 0.1% cream to affected area BID 7-10 days -Benadryl 25-50mg Oral PRN 4-6 hours as needed for itching (Do not exceed 300mg per day) Education: -Gentle cleansing of area with lukewarm water and non fragrance soap -when in wooded areas stay protected and clothed with no skin exposure risk to irritants - avoid scratching -cool compresses -Avoidance of further exposure to suspected irritants/allergens (Litchman et al., 2023) (Non pharmacological treatments greatly impact the outcome/treatment of contact dermatitis) Follow up: -1 week or sooner if worsening or if signs or symptoms of infection develop -Go directly to ER or call 911 if you develop Shortness or breath, throat or lip swelling Referrals: -Will consider Dermatology referral for testing if rash reoccurs or etiology remain unclear (Litchman et al., 2023) References: Litchman, G., Nair, P., Atwater, A., & Beenish, B. (2023). Contact Dermatitis. State Pearls. https://www.ncbi.nlm.nih.gov/books/NBK459230 Attempt: 3715524 Report generated on 11/1/2025, 5:09:11 PM America/Denver Family History Category Data entered by Sarah Wright Family History Mother-No known medical problems Father-HTN Brothers-No known medical problems Sister-No known medical problems Maternal Grandfather-Died at 81 CVD Maternal Grandmother-88 year old hx of HTN, stent placement and MI Social History Category Data entered by Sarah Wright Social History Monogamous relationship,sexually active, reports occasional ETOH use, denies tobacco or recreational drugs Review of Systems Category Data entered by Sarah Wright General Generally well appearing, Denies fever and fatigue. reports overall health is "good" denies any recent excessive weight gain or loss Integumentary / Breast Reports rash to bilateral upper thighs and inner left forearm. Rash not present anywhere else at this time HEENT / Neck Head:Denies headache Ears:Denies hearing loss Eyes:Denies complaints (denies blurry vision) Nose:Denies any issues with nasal drainage Throat/Neck:Denies sore throat, Denies throat swelling Cardiovascular Denies any chest pain,Denies extremity swelling, Blood pressure and pulse normal Respiratory Denies Shortness of breath, Denies Cough, RR normal Gastrointestinal Denies nausea or vomiting or diarrhea Genitourinary Denies complaints Musculoskeletal Denies problems with joint pain/swelling/ or redness. Pt denies any neck pain Allergic / Immunologic Received childhood immunization up to date on immunizations,