ihuman case Study Gemma Jones 2yrs Old CC Abdomen Rash, Exams of Nursing

Download ihuman case Study Gemma Jones 2yrs Old CC Abdomen Rash and more Exams Nursing in PDF only on Docsity! ihuman case Study Gemma Jones 2yrs Old CC: Abdomen Rash The following whether you Time spent: table hr Status: Submitted cert Section Total Score History Physical exams Key _ findings organization Problem statement Differentials Differentials ranking Tests Diagnosis Management plan Attempt: Done Done Done Done Done Done Done Done Done summarizes. your completed that section or 18min 17sec ACT art BTC ig 97% TO 10min 28sec 94% 17min c 54sec 3min ec 80% 10sec 39sec 100% (lead/alt score) 0% (must not miss score) 3min 100% c 100% 24sec 12min 22sec performance on each section of not. aaa Dry 17 questionsasked, 16 relative to the 36 exams _ performed, 8se partially correct, 0 case's list 4 findings listed; 5 70 words long; the 55s i} items in the missed relative to ase 2 tests ordered, 0 relative to the 210 words long; _ the correct, case's 12 missed listed case's DDx, the correct, case's case's the case, 0 missed list correct, 1 relative to the by the case was 76 words 4 correct, 1 case's _ list 0 missed list was 37 words 2490513 Report generated on Gemma developing identified from the History Notecard by Jessica Szymanski = on case Use this worksheet to organize your thoughts before diagnosis list. 1. Indicate key symptoms (Sx) you have patient's reason(s) for the encounterand add further questioning. 2. Characterize the attributesof each symptom using the appropriate column and row. 3. Review your findings and consider possible diagnoses symptoms. (Remember to consider the your ideas to help guide your physical section of the case. HPI Sx = Sx = Sx = Onset Location Duration Characteristics Aggravating Relieving Timing / Treatments Severity additional "OLDCARTS". that may patient's age examination Sx = Jones a differential history. Start with the symptoms obtained from Capture the correlate with and risk in the Sx = details in these factors.) Use next Electronic Health Record by Jessica Szymanski on case Gemma Jones History of PresentilIness fella Data Cc mye BUS ie MTC 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 Dr) a Ble MU Past Medical History None. Hospitalizations / Surgeries Born full term at 38 weeks GA with no complications. Drie) ae Bl Ms TU Social History Lives at home with mother and father in an apartment. Medications Dr) entered by Be Ud Medications PRN Tylenol Allergies Dr) entered by Be MUU Allergies NKA. Preventive Health fella Data entered by este MTL a Preventive health Has been meeting developmental milestones, growing and developing well. Family History folie Data entered by Bs tie MTL a Family History Mother and father healthy. Social History Review Systems Ge CoH) Eakins General Integumentary HEENT / Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Allergic / Endocrine Hematologic Neurologic Psychiatric Physical pa Ge by dei) Gye General Skin HEENT / Cardiovascular Chest / Abdomen Genitourinary / Breast Neck Immunologic / Lymphatic Exams Neck Respiratory / Rectal Alert, c/o fevers. No bruising. C/O rash. No eye or ear discharge, no conjunctivitis, no recent head trauma. C/O runny nose. No hx of murmur, no SOB, no hx of fainting. No wheezing or SOB. c/o cough. No vomiting, diarrhea or constipation. Mother reports formed stools twice a day and no change in appetite. Wears diapers, no hx. of UTIs, Has 45 wet diapers per day. No recent trauma, weaknessor limping. No allergies. Immunizations UTD. No hx of diabetes or thyroid dysfunction. No hx of anemia. No hx. of seizures. Happy child. 0 fever — (-) appetite change Warm and dry, (+) significant weight change maculopapular _ pink abdomenand extremities (+) rhinorrhea (+) cough ©) CP/pressure/discomfort © decrease in (+)acute cough (-) SOB (-) wheezing (-) breath (-) chronic cough () sputum production Diaper stools about 2 per day Diaper urine 4-5 per day ihuman case Study Gemma Jones 2yrs Old CC Abdomen Rash (-) significant rash on the activity (-) SOB difficulty catching a