Gemma Jones Ihuman Case Study Reason for Encounter Rash, Exams of Nursing

Download Gemma Jones Ihuman Case Study Reason for Encounter Rash and more Exams Nursing in PDF only on Docsity! 1 ihuman Case Study Gemma Jones 2yrs Old CC: Abdomen Rash The following table summarizes your performance on each section of the case, whether you completed that section or not. Time spent: 1hr 18min 17sec Status: Submitted Case Section Status Your Score Time nt spe Perfor mance Details Total Score 97% History Done 100% 10min 28sec 17 questionsasked, 16 relative to the correct, case's 0 missed list Physical exams Done 94% 17min c 8se 36 exams performed, partially correct, 0 case's list 12 missed correct, 1 relative to the Key findings organization Done 54sec 4 findings listed; 5 listed by the case Problem Done 3min ec 55s 70 words long; the case's was 76 words statement Differentials Done 80% 10sec 5 items in the missed relative to DDx, the 4 correct, 1 case's list Differentials ranking Done 100% (lead/alt 39sec score) 0% (must not miss score) Tests Done 100% 3min c 2se 2 tests ordered, 0 relative to the correct, case's 0 missed list Diagnosis Done 100% 24sec Management Done 12min 210 words long; the case's was 37 words plan 22sec Attempt: 2490513 Report generated on 2 History Notecard by Jessica Szymanski on case Gemma Jones 9/9/2022, 1:02:15 PM America/Denver 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 attributesof 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: 2490513 Report generated 5 Electronic Health Record by Jessica Szymanski on case Gemma Jones History of Present Illness Category Data entered by Jessica Szymanski Reason for Encounter Rash History of present illness Presents with cough, runny nose, fever and new onset rash. Fever started 3 days ago, stopped last evening. Cough and rhinorrhea also started 3 days ago. Past Medical History Category Data entered by Jessica Szymanski Past Medical History None. Hospitalizations / Surgeries Born full term at 38 weeks GA with no complications. Category Data entered by Jessica Szymanski 6 Social History Lives at home with mother and father in an apartment. Medications Category Data entered by Jessica Szymanski Medications PRN Tylenol Allergies Category Data entered by Jessica Szymanski Allergies NKA. Preventive Health Category Data entered by Jessica Szymanski Preventive health Has been meeting developmental milestones, growing and developing well. Family History Category Data entered by Jessica Szymanski Family History Mother and father healthy. Social History 7 Review of Systems Category Data entered by Jessica Szymanski General Alert, c/o fevers. Integumentary / Breast No bruising. C/O rash. HEENT / Neck No eye or ear discharge, no conjunctivitis, no recent head trauma. C/O runny nose. Cardiovascular No hx of murmur, no SOB, no hx of fainting. Respiratory No wheezing or SOB. C/O cough. Gastrointestinal No vomiting, diarrhea or constipation. Mother reports formed stools twice a day and no change in appetite. Genitourinary Wears diapers, no hx of UTIs, Has 4-5 wet diapers per day. Musculoskeletal No recent trauma, weaknessor limping. Allergic / Immunologic No allergies. Immunizations UTD. Endocrine No hx of diabetes or thyroid dysfunction. Hematologic / Lymphatic No hx of anemia. Neurologic No hx of seizures. Psychiatric Happy child. Physical Exams Category Data entered by Jessica Szymanski General (-) fever (-) significant weight change (-) significant appetite change Skin Warm and dry, (+) maculopapular pink rash on the abdomen and extremities HEENT / Neck (+) rhinorrhea (+) cough Cardiovascular (-) CP/pressure/discomfort (-) decrease in activity (-) SOB Chest / Respiratory (+)acute cough (-) SOB (-) wheezing (-) difficulty catching a breath (-) chronic cough (-) sputum production Abdomen Diaper stools about 2 per day Genitourinary / Rectal Diaper urine 4-5 per day