IHUMAN CASE STUDY DERMATOLOGY GEMMA JONES 2yrs Old CC ; Encounter Rash, Exams of Nursing

Download IHUMAN CASE STUDY DERMATOLOGY GEMMA JONES 2yrs Old CC ; Encounter Rash and more Exams Nursing in PDF only on Docsity! IHUMAN CASE STUDY DERMATOLOGY GEMMA JONES 2yrs Old CC ; Encounter Rash PHYSICAL EXAM: VITAL SIGNS - Optional © You must look at vitals in the EHR (current visit) to get credit. PERFORMING YOUR PHYSICAL EXAM: © Perform those physical assessment maneuvers as needed © Document in Key Findings ASSESSMENT: © Organize Key Findings by selecting the MSAP (Most Significant Active Problem) © Mark other findings as: related, unrelated, unknown, or PMH/resolved PROBLEM STATEMENT: © Short Summary of patient's presentation. Should contain: 1) demographic description, 2) chief complaint, 3) History and Physical Exam key findings, 4) risk factors. Keep it concise. DIFFERENTIAL DIAGNOSIS: ® List diseases you are considering prior to ordering tests. © Select lead, alternate, and “Must-Not-Miss” differentials (“Must-Not-Miss” = has significant morbidity or mortality if missed, or leads to communicable concerns). Temp: 97.0 °C (98.6 °F) (oral) Pulse: ‘80 bpm, rhythm: regular BP: left: 90/65, Respiration: 22pm Weight: 11.8 kg (26.0) HEENT/Neck: Normocephalic, atraumatic No stridor Trachea midline; No mass or lymphadenopathy Right and left tympanic membranes normal. No erythema) ‘of ear canals bilaterally. No erythema and exudates of the pharynx. Cardiovascular: Normal PMI RR and R, no murmur or gallop (Chest / Respiratory: Normal respiratory effort and excursion Breath sounds equal with no wheezing or crackles. ‘Abdomen: ‘soft, non-tender, non-distended No hepatosplenomegaly, mass, or hemiation Neurologic: ‘Awake and alert. Moves all extremities wel. ‘Musculoskeletal / Osteopathic Structural Examination: ‘Normal gait and coordination. Moves all extremities well. No erythema or swelling, Genitourinary /Rectal: Normal female. No erythema of labia. No diaper rash. ‘Skin: ‘Well hydrated, normal turgor and color. No rashes. No bruises. No petechiae. Lymphatic: ‘No lymphadenopathy. Hematologic: 'No conjunctival pallor No bleeding sites. 18 month old female here for well child check, doing well. Growing and developing well. « Anticipatory guidance given + Will get booster vaccines today: Hep A 2nd dose + Return for 2 year old well child check History Feedback Below you will see the strategy for selecting the "required" questions in this patient encounter using the OLD-CARTS mnemonic for the HPI. Reason for Encounter Start wth open-ended patient-centric questions. © Asked X Not asked Graded Approach Question Response oa ‘She has had a rash since this ‘morning that has spread a lot. Quite © —CCSx How can I help her today? (witness) iarming to me! Do you think shell wind up with scars? Does she have any other symptoms © Assoc Sx or concems we should discuss? Well she has a cough and runny (witness) : a ox apse ben nag ears? Yas has ‘She's been eating and drinking well How is her appetite? Any recent © Etiology 7 (wioes) Seoighoat a offi. No targets OLD-CARTS for the HPI @ Asked X Not asked Information Graded Approach Question Response Obtained Clinic Notes Yes, did! tel you about that Did she have anyother problems seat? That's actualy when her @ Onset ‘two to four days before the rash istartad..tiee tiaya ago, You, know, the runny nose and such. started? (witness) i ; She didnt have a rash or anything like that then, Three days ago, but its gone now. © Onset Wen dd her fever start? (witness) yoo Cae. 200, bul t's Gone no (On what part of her body did the It started on her abdomen and © Location rash star and where did it spread? ce nena ag (witness) Duration No, Laven‘ noticed her itching it. © Characteristics (Snes Painful or chy? guess | can't be sure it doesnt hurt, etre but | dont think so. Is she coughing up any sputum? © Characterisies (he Not that ve noticed. Aggravating Relieving : ‘What treatments has she had for Nothing so far. Is there something | © Timing/Treatments rer cough? (witness) should be giving her? Nothing. | hope you can give her © Timing/Treatments nat eatments nas she had for something that will make i go away. (otinaee Wilt leave any scars on her? @ Severity How high is her fever? (witness) It was 103 two days ago. HPI PMH, FH, SH as Needed © Asked X Not asked Graded Approach Question Response nee How many wet diapers does your Ce ere emcee About 4-5. That hasnt changed How many stool diapers does your Cn ee err aaet YOU About 2 per day. @ Pun —_|Sshetaking any over-the-counter | had been giving her Tylenol. or herbal medications? (witness) That's it © pun —_Doesshehave any allergies? Not before this. Do you tink this is (witness) an allergy? Review of Systems (ROS) Select the major body systems that have not been touched on during the interview process for the HPI. @ Asked X Not asked Name: Gemma Jones Age: 2ylo Sex: F Height: 34" Weight: 28 Ib BMI: 17 Cognitive status: AandO x4 Temp: 37.0 °C (98.6 °F) (oral) Pulse: 75 bpm, rhythm: regular, strength: normal BP: left: 90/60, right: 95/60, assessment: normotensive, pulse pressure: normal Respiration: 22 bpm, rhythm: regular, effort: unlabored SpO.; 94% Physical Exam Feedback © Performed Correctly + auscultate abdomen © You performed the simulation correctly. © You interpreted assessment correctly. auscultate heart © You performed the simulation correctly. © You interpreted assessment correctly. auscultate lungs © You performed the simulation correctly. © You interpreted left lung and right lung correctly. ‘examine pupils © You performed the simulation correctly © You interpreted left pupil and right pupil correctly. + inspect ears In a patient with runny nose and cough, a full HEENT exam must be done to check for signs of infection. + inspect eyes In a patient with runny nose and cough, a full HEENT exam must be done to check for signs of infection. inspect mouth/pharynx In a patient with runny nose and cough, a full HEENT exam must be done to check for signs of infection. + inspect nose In a patient with runny nose and cough, a full HEENT exam must be done to check for signs of infection. « inspect skin overall In a patient with a rash, a thorough exam of the skin must be done. + look in ears with otoscope Ina patient with runny nose and cough, a full HEENT exam must be done to check for signs of infection. look up nostrils In a patient with runny nose and cough, a full HEENT exam must be done to check for signs of infection. Your Differential Diagnoses Legend: @ Correct @ exanthema subitum (HHV-6/roseola) @ human parvovirus 19 @ measles (rubeola) @ rubella (German measles) @ viral upper respiratory infection (URI) Feedback @ Correct 1. exanthema subitum (HHV-6/roseola) 2. human parvovirus 19 3. measles (rubeola) 4. rubella (German measles) 5. viral upper respiratory infection (URI) Your Differential Ranking © Correct € Extraneous Your Differential Diagnosis Lead Graded exanthema subitum (HHV-6/roseolay © @ human parvovirus 19 ° measles (rubeola) ° rubella (German measies) ° Viral upper respiratory infection (URI) © ©0000)/zRf sooog if oi ck Feedback ‘This patient has had a cough and runny nose along with a fever that has subsided followed by a rash, roseola is our leading diagnosis in this case. Parvovirus B19 which is also known as erythema infectiosum or fitth disease, can present with a fever and cough, but it also presents with a lacy rash on both cheeks which can then spread to the abdomen and extremities. Gemma’s rash did not present on her cheeks. Therefore, this is a diagnosis we can consider, but is an alternate diagnosis in this case. Before the era of vaccination, measles and rubella were more common. Both measles and rubella can present with a fever and cough; however, Gemma does not have koplik spots that are commonly seen in measles or a rash that spread from face ‘downwards that is commonly seen in rubella. Gemma is also up to date on her vaccinations. Therefore these are alternate diagnoses in this case. ‘This patient does have common signs of an upper respiratory infection, however the presence of a rash appearing after the fever makes roseola the leading diagnosis in this case and therefore URI is an alternate diagnosis. No need for tests Diagnostics Feedback @ Correct Diagnosis Feedback Because of the presentation of cold symptoms and a fever that resolves before the rash appears, roseola isthe diagnosis in this case.