Download Performance Overview for Jessica Rhyan on case Gemma Jones and more Exercises Nursing in PDF only on Docsity! I-HUMAN EXAM: Performance Overview for Jessica Rhyan on case Gemma Jones The following table summarizes your performance on each section of the case, whether you completed that section or not. Time spent: 7hr 30min 57sec Status: Submitted Case Section Stat us Your Score Time spent Performance Details Total Score 100% History Don e 100% 8min 54sec 17 questions asked, 16 correct, 0 missed relative to the case's list Physical exams Don e 100% 11min 53sec 23 exams performed, 13 correct, 0 partially correct, 0 missed relative to the case's list Key Qindings organization Don e 8min 22sec 4 Qindings listed; 5 listed by the case Problem statement Don e 14min 0sec 75 words long; the case's was 76 words Differentials Don e 100% 6min 30sec 5 items in the DDx, 5 correct, 0 missed relative to the case's list Differentials ranking Don e 100% (lead/ alt score) 0% (must not miss score) 1hr 6min 59sec Tests Don e 100% 2hr 39min 4sec 0 tests ordered, 0 correct, 0 missed relative to the case's list Diagnosis Don e 100% 10sec Management plan Don e 54min 33sec 238 words long; the case's was 37 words History Notecard by Jessica Rhyan on case Gemma Jones Use this worksheet to organize your thoughts before developing a differential diagnosis list. 1. Indicate key symptoms (Sx) you have identiQied 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 Qindings 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 Characteristic s Aggravating Relieving Timing / Treatments Severity Electronic Health Record by Jessica Rhyan on case Gemma Jones History of Present Illness Past Medical History Medications Allergies Preventive Health Family History Category Data entered by Jessica Rhyan Reason for Encounter Rash on abdomen and bilateral upper and lower extremities History of present illness 2-year-old Gemma Jones presents to the ofQice, with her mother. Mother states the patient had a fever for the last 3 days, which stopped last evening. Additionally, complains of cough and rhinorrhea for 3 days. The rash started on her abdomen this morning and spread to her upper and lower extremities. Mom was giving Tylenol, based on the manufacturer directions, and stopped when the fever subsided. Category Data entered by Jessica Rhyan Past Medical History None Hospitalizations / Surgeries born full term 38 weeks GA, via NSVD Category Data entered by Jessica Rhyan Medications none Category Data entered by Jessica Rhyan Allergies NKDA Category Data entered by Jessica Rhyan Preventive health growing and developing well - reaching developmental milestones. UTD on current vaccinations Category Data entered by Jessica Rhyan Family History Mother 32 - healthy Father 35 - healthy Social History Review of Systems Physical Exams Category Data entered by Jessica Rhyan Social History Lives in an apartment with both parents Category Data entered by Jessica Rhyan General denies fever, weight change, and change in appetite Integumentary / Breast admits to rash on abdomen and upper and lower extremities HEENT / Neck admits to rhinorrhea and cough Cardiovascular denies fatigue, SOB Respiratory admits to cough, denies SOB, wheezing, sputum Gastrointestinal diaper stools about two per day Genitourinary urine diapers 4-5 per day Musculoskeletal denies change in strength and range of motion Allergic / Immunologic Endocrine Hematologic / Lymphatic denies Neurologic denies, no history of seizure Psychiatric Category Data entered by Jessica Rhyan General a/o x4, normal appearance, active, well-developed Skin pink maculopapular rash on abdomen and upper and lower extremities HEENT / Neck Head/neck - Normocephalic, full ROM of neck, no tenderness EENT - Eyes- PERRLA. No erythema, drainage, swelling noted. Ears - No tenderness to palpation, drainage, erythema or bulging to TM noted. Nose - No erythema, drainage, or tenderness to palpation noted. Throat - Moist, pink. No ulcers. Normal dentition and gums. No tonsillar exudate Cardiovascular RRR. No murmurs noted. Negative for bilateral lower extremity edema Chest / Respiratory Chest expansion is symmetrical. Lungs are clear to auscultation. Abdomen Flat, symmetric, no deformities Genitourinary / Rectal Musculoskeletal / Osteopathic Structural Examination Neurologic Psychiatric Lymphatic no bleeding or bruising noted. No enlarged, swollen lymph nodes in the cervical, supraclavicular, axillary and inguinal chains