NR 601 Week 3 iHuman Performance Overview Report on Case Regina Ricardo, Lab Reports of Nursing

Download NR 601 Week 3 iHuman Performance Overview Report on Case Regina Ricardo and more Lab Reports Nursing in PDF only on Docsity! Performance Overview on case Regina Ricardo The following table summarizes your performance on each section of the case, whether you completed that section or not. Time spent: 2hr 18min 25sec Status: Submitted Case Section Status Your Score Time spent Performance Details History Done 89% 58min 39sec 100 questions asked, 31 correct, 4 missed relative to the case's list Physical exams Done 75% 18min 4sec 52 exams performed, 16 correct, 2 partially correct, 4 missed relative to the case's list Key findings organization Done 38sec 9 findings listed; 9 listed by the case Problem statement Done 45sec 67 words long; the case's was 85 words Differentials Done 100% 33sec 5 items in the DDx, 4 correct, 0 missed relative to the case's list Differentials ranking Done 50% (lead/alt score) 50% (must not miss score) 0sec Tests Done 100% 10min 26sec 4 correct tests ordered, 5 extraneous, 0 missed relative to the case's list Diagnosis Done 100% 13sec Management plan Done 10min 12sec 255 words long; the case's was 46 words Exercises Done 98% (of scored items only) 8min 33sec 5 of 6 correct (of scored items only) 1 partially correct Attempt: 2564156 Report generated on 11/8/2022, 2:06:33 PM America/Denver History Notecard by Jessica Szymanski on case Regina Ricardo 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 = trouble sleeping Sx = nervousness Sx = loose stools Sx = weight loss Sx = intole Onset a couple months ago a couple months ago a couple months ago unknown a coup month Location generalized thoughts GI tract generalized gener Duration ongoing, multiple times a week ongoing ongoing new, just noticed weight today ongoi Characteristics trouble falling asleep and staying alseep frequent "in the background" loose but not diarrhea weight loss despite increased appetite wors e when playin tenni s Aggravating night time unknown caffiene unknown actvity Relieving nothing nothing avoiding caffiene but still unresolved unknown rest Timing / Treatments none none none none none Problem Statement by Jessica Szymanski on case Regina Ricardo Patient is a 65 year old female who presents with complaints of trouble sleeping. Insomnia started a couple months ago and was intermittent, now it is multiple times a week. She also has been experiencing an increase in daily bowel movements, nervousness, resting tremor and sweaty palms, increased appetite, hair thinning, and palpitations. On exam her thyroid is enlarged, she is tachycardic, has hyperreflexia, and lid lag. Attempt: 2564156 Report generated on 11/8/2022, 2:06:33 PM America/Denver Management Plan by Jessica Szymanski on case Regina Ricardo Subjective: presents with complaints of trouble sleeping. Insomnia stared a couple months ago and was intermittent, now it is multiple times a week. She also has been experiencing an increase in daily bowel movements, nervousness, resting tremor and sweaty palms, increased, appetite, hair thinning, unintentional weight loss and palpitations. Her grandmother had a history of “thyroid problems”. Objective: on exam her thyroid is enlarged, she is tachycardic, has hyperreflexia, dry hair, and lid lag. Diagnostics: TSH is low, TSI is elevated, FT4 is elevated, and thyroid scan is consistent with Grave’s disease. Assessment: Hyperthyroidism due to Grave’s disease is the leading diagnosis due to symptoms, diagnostics, and family history of thyroid problems. The poorly defined onset of symptoms, palpable thyroid isthmus, and asymmetrical gland is typical with Grave’s disease. Plan: propylthiouracil (PTU) is an oral medication that is used to manage hyperthyroidism which is due to an overactive thyroid gland. Start by taking 300 mg/day in three divided doses every 8 hours. After initial treatment, the general maintenance dose is 100 to 150 mg/day. Consider a thyroid scan, radioactive iodine, thyroid ablations and surgical resection. Possible endocrinology consult for management if scan shows nodules. Discuss lifestyle changes and diet. Education: nervousness, anxiety, goiter, weight loss, increase in bowel movements, sleeping problems, tachycardia, and tremors are caused by hyperthyroidism, also known as overactive thyroid, which can speed up your metabolism and cause these symptoms. PTU can be taken from 6 months to several years, with an average duration of one year. Follow up: in 4 weeks Attempt: 2564156 Report generated on 11/8/2022, 2:06:33 PM America/Denver Electronic Health Record by Jessica Szymanski on case Regina Ricardo History of Present Illness Category Data entered by Jessica Szymanski Reason for Encounter trouble sleeping History of present illness patient has problems both falling asleep and staying asleep. Past Medical History Category Data entered by Jessica Szymanski Past Medical History none Hospitalizations / Surgeries none Medications Category Data entered by Jessica Szymanski Medications calcium and multivitamin Allergies Category Data entered by Jessica Szymanski Allergies NKA Preventive Health Category Data entered by Jessica Szymanski Preventive health immunizations UTD Family History Category Data entered by Jessica Szymanski Family History grandmother had thyroid problems. Social History Category Data entered by Jessica Szymanski Social History nonsmoker, drinks 1-2 alcoholic drinks per week, goes out with friends, walks and plays tennis on the weekends, retired.