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Download iHuman Case Study Week 2: Victoria Lewis (25-Year-Old Female with New Rashes) | Complete D and more Exams Nursing in PDF only on Docsity!
Performance Overview for Kayla Grey on case Victoria Lewis V5.1 PC PL @ Human ‘The following table summarizes your performance on each section of the case, whether you completed patients that section or not. hy LAN, Time spent: 8hr 45min 7sec Status: Submitted Y eee stan || Hepat |peeean nets Score History Done 100% 3hr1imin | 48 questions asked, 18 correct, 0 missed relative to the expen's list S7sec Done | 69% lbr34min 24 exams performed, 3 correct, 2 missed relative to the expert's list 2sec Key findings Done 43min 7 findings listed; 6 listed by expert organization 3lsec Problem Done 8min 32sec 70 words long; expert's was 77 words statement Body system Done 100% 13sec 1 of 1 correctly picked plus 0 extras classification Differentials Done = 40% 6min 42sec 5 items in the DDx, 2 correct, 3 missed relative to the expert's list Differentials Done 100% 6min 11sec ranking Clead/alt score) 40% (must not miss score) Tests Done 100% 7min 22sec 1 test ordered, 0 correct, 0 missed relative to the expert's list Diagnosis Done 100% 7sec Management Done lbr 26min 233 words long; expert's was 99 words plan 3sec Exercises Done 93% 7min 10sec 4 of 5 correct (of scored items only) 1 partially correct (of scored items only) Attempt: 2282253 @ Human History Notecard by Kayla Grey on case Victoria Lewis V5.1 PC PL patients’ by KAPLAN) 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 HPI Sx =rash pa a aa ai is Onset 36 hours Location inner thighs and left inner forearm Duration constant Characteristics itching and tender Aggravating none Relieving none Timing / none Treatments Severity unknown @ Human Management Plan by Kayla Grey on case Victoria Lewis V5.1 PC PL patients’ by KAPLAN, Dx: Allergic Contact Dermatitis Therapeutic treatments: non-pharmacological- gentle cleansing of affected area with lukewarm water and nonfragranced antibacterial soap or astringent soak, cool wet compresses, and avoid scratching. Pharmacological- topical and/or systemic steroids and antihistamines. Triamcinalone 0.5% topical cream applied to affected area BID x 5-7 days Medrvl dose Pak 4mg as directed (24mg on day one, 20mg on day 2, L6mg on day 3, 12mg on day 4, 8mg on day 5, and 4mg on day 6) Benadryl 12.5-25mg OTC every 4-6 hours as needed for itching No consults needed at this time. Educati' This patient has risk factors of hiking which can expose patient to numerous plants and insects, use of hot tub, use of new suntan lotion and ingestion of new food/drink. Education shauld be provided on avoiding allergen if at all possible and if skin comes into contact with it, such as poison ivy, poison oak, and poison sumac, the skin should be washed with mild soap and water immediately. There is also a patch test method when using new lotions, soaps, perfumes, etc. that may prevent future allergic reactions. Most importantly avoid scratching to prohibit further skin irritation and spread of reaction. With this treatment the patient should see some relief in 1-2 days, but if it worsens the patient should come back into clinic for futher evaluation and treatment due to the possibility of a secondary infection. @ Human Electronic Medical Record by Kayla Grey on case Victoria Lewis V5.1 PC PL patients by KAPLAN, History of Present Illness Reason for Encounter rash to upper thighs and left forearm History of present illness V.L. is a 25 y/o Caucasian female that presents today with a rash that is itchy and getting tender to bilateral upper thighs and inner left forearm. The rash started approximately 36 hours ago after hiking in the woods and "bush whacking" her way back to the trail. No treatments have been tried and no known aggravating or alleviating factors. Past Medical History Other active problems none Medical, surgical, obstetric, none hospitalizations Medications Category Data entered by Kayla Grey Rx (medications) Birth Control Pill Allergies Allergies Ceclor or Cefaclor - hives as a child Preventive Health Preventive health | Up to date on all immunizations Exercises regularly Normal American diet Physical Exams ga Hata css Re General Skin/Breast HEENT & neck Cardiovascular Respiratory Abdomen/Gastrointestinal Genitourinary Musculoskeletal Osteopathic Neurological Psychological Lymphatic/Endocrine Attempt: A/O x 4, dressed appropriately. BP 116/80, pulse GOBPM, respirations 13, Spo2 94%, and temperature 98.6 Left forearm have itchy erythematous papules linear with vesicles. Bilateral inner upper thighs have raised erythematous papules with vesicles in various stages. Trachea midline, thyroid firm and normal size for age and gender, no nodules. PMI Sth ICS at the MCL. $1 and S2 noted. No murmurs, gallops, or rubs. Normal respirations, no shortness of breath or distress. No wheezing, crackles, or rales upon auscultation. No distention, scars, or masses noted. Flat, symmetric, no scars, deformities, striae, or lesions. Hyperactive bowel sounds in all quadrants. No pain, tendemess, massess, or pulsations. No guarding or rebound tendemess, no hepatosplenomegaly, liver span normal, spleen not palpable. N/A No stiffness in joints. No swelling, deformities, cyanosis, clubbing or edema in extremeties. N/A N/A N/A No swollen lymphnodes. 
