Download Influenza Case Management for College Student and more Assignments Nursing in PDF only on Docsity! Performance Overview for Amy Nelson on case Marvin F. Webster The following table summarizes your performance on each section of the case, whether you completed that section or not. Time spent: 2hr 5min 9sec Status: Submitted Case Section Status Your Score Time spent Performance Details History Done 100% 19min 36sec 42 questions asked, 21 correct, 0 missed relative to the case's list Physical exams Done 100% 16min 54sec 25 exams performed, 10 correct, 0 partially correct, 0 missed relative to the case's list Key findings organization Done 2min 12sec 6 findings listed; 8 listed by the case Problem statement Done 4min 50sec 81 words long; the case's was 68 words Diagnosis Done 100% 3sec Management plan Done 23min 10sec 149 words long; the case's was 112 words Exercises Done 100% (of scored items only) 36sec 1 of 1 correct (of scored items only) Attempt: 2557740 Report generated on 11/4/2022, 2:31:19 PM America/Denver History Notecard by Amy Nelson on case Marvin F. Webster 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: 2557740 Report generated on 11/4/2022, 2:31:19 PM America/Denver Electronic Health Record by Amy Nelson on case Marvin F. Webster History of Present Illness Category Data entered by Amy Nelson Reason for Encounter Pt reports they feel awful with body aches, cough, and feeling exhausted. History of present illness M. W. 18-year-old healthy male with a sore throat, cough, and headache x 4 days. pt rates of sore throat 6-8 out of 10 pain. pt states it feels like swallowing razor blades. pt states he has tried otc ibuprofen and steam, which does not relieve the pain. Pt states headache is mild and is relieved by ibuprofen. Pt states that his cough is dry and nothing makes it better or worse. pt states for the past 2 days he has had increased fatigue. Pts roommate was sick x 1 week ago Past Medical History Category Data entered by Amy Nelson Past Medical History Childhood asthma- no issues with recent flair ups Hospitalizations / Surgeries None Medications Category Data entered by Amy Nelson Medications no medications daily. Allergies Category Data entered by Amy Nelson Allergies No known drug allergies Preventive Health Category Data entered by Amy Nelson Preventive health covid vaccine x2 Family History Category Data entered by Amy Nelson Family History dad 57 years old in good health. Mom is 58 with a hx of hypertension Social History Category Data entered by Amy Nelson Social History A college student lives with a roommate Occasional beer on the weekends Review of Systems Category Data entered by Amy Nelson General Pt states he feels awful and exhausted. Integumentary / Breast HEENT / Neck + sore throat Cardiovascular denies chest pain, discomfort, or pressure. Denies dizziness and palpitations. pt denies having blue or cold fingers. Respiratory + Nonproductive cough Denies shortness of breath and wheezing Gastrointestinal denies nausea, vomiting, and constipation. no blood in stool noted Genitourinary Musculoskeletal + myalgia Allergic / Immunologic Endocrine Hematologic / Lymphatic Neurologic Negative for seizures, fainting, or dizzy spells. Denies numbness or tingling in fingers Psychiatric Physical Exams Category Data entered by Amy Nelson General Awake, alert, and oriented x 4. No acute distress, well developed, and appears age- stated. Skin Warm, dry, and intact with no rashes noted. Appropriate color for ethnicity. HEENT / Neck Ears: The external ear and ear canal are non-tender and without swelling. The canal is clear without discharge. The tympanic membrane is normal in appearance. Throat: oral mucosa is pink and moist. The pharynx has erythema and exudate noted, along with tonsillar swelling noted. Neck: full range of motion noted, no nuchal rigidity noted, + tender 0.8 cm to 1.0 cm anterior cervical lymph node swelling and pain. Cardiovascular The external chest is normal in appearance, with no tenderness, lumps, or masses noted. No murmurs, gallops, or rubs were noted. Pt is tachycardic. Chest / Respiratory Chest: No tenderness, lumps, or masses. anterior fields are resonant, left anterior chest and lower chest are dull to percussion. rest of the lung fields are resonant and not hyper-resonant. lungs are clear anterior and posterior. Abdomen Soft, non-tender, Liver normal size, Spleen normal size Bowel sounds normoactive, No tympany or shifting dullness Genitourinary / Rectal Not examined Musculoskeletal / Osteopathic Structural Examination Not examined Neurologic Not examined Psychiatric Not examined Lymphatic + tender 0.8 cm to 1.0 cm anterior cervical lymph node swelling and pain. Attempt: 2557740 Report generated on 11/4/2022, 2:31:19 PM America/Denver
