NRNP – 6531 Week 2: Kaylee Hales Derm iHuman Case Study

NRNP – 6531 Week 2: Kaylee Hales Derm iHuman Case Study

This information should be included in your i-Human cases:

Patient History (HPI): You will enter this in the EMR section of the case (NOT the problem statement).

This is where you describe the patient’s symptoms. Good documentation here is important for patient care, coding, and billing analysis. Paint a clear picture of what’s wrong with the patient. This part deals with how the patient feels. To do this, use the LOCATES or OLDCARTS Mnemonic to describe the patient’s symptoms. Always start with the patient’s age, race, and gender (for example, “34-year-old African American male”). Write about the seven aspects of each main symptom in paragraphs, not as a list. Also, mention any relevant historical information that could affect the differential diagnosis. If the chief complaint was “headache,” the HPI would include the following information:

– Location: The head
– Onset: Three days ago
– Character: A throbbing, intense feeling around the eyes and temples
– Associated signs and symptoms: Feeling sick, throwing up, sensitivity to light, and sensitivity to sound
– Timing: Usually happens after spending the whole day on the computer at work
– Factors making it worse or better: Bright light makes it worse, taking Aleve helps a bit but doesn’t completely get rid of it
– Severity: Pain level is 7 out of 10

Patient Plan: Enter the information for each of these sections into the i-Human Plan section of your case. You must address all six topics. For example, if you don’t need to consult anyone, you should write “no consults indicated.” Each section of the plan is worth 5 points, totaling 30 points.

NURS 6512 week 2 discussion – BK is a 16-year-old Caucasian female

Additional labs or diagnostic tests: Sometimes, more tests may be needed to diagnose or evaluate a condition. Some tests, like an MRI, might need approval from the patient’s insurance company.

Consults: This includes referrals to specialists, therapists (physical or occupational), counselors, or other professionals. If you’re sending the patient to the hospital, what orders would you write for a direct admission?

Therapeutic modalities: This covers how to manage the patient’s condition, including medications, dosages, and how long to take them. It also includes expected treatments if the patient goes to the emergency department or is directly admitted.

Health Promotion: Think about addressing risk factors, if relevant. Consider recommending age-appropriate preventive health screenings and vaccinations.

Patient education: Explain the diagnosis and treatment plan to the patient and their family.

Disposition/follow-up instructions: Include when the patient should return for a follow-up in the clinic or see a specialist or therapist. Specify when they should return sooner or go to the emergency department, urgent care center, or another facility.

Finally, include at least three recent, scholarly references to support your plan, following current care standards. Do not use the course textbook as a reference. These references should be professional, not general patient education websites.

Assignment: i-Human Case Study: Evaluating and Managing Skin Conditions

In this course, you’ll complete a series of case studies using the i-Human software application. This tool allows you to interact with virtual patients to learn patient assessment and diagnostic reasoning skills. With i-Human, you can independently interview, examine, diagnose, and treat virtual patients and receive expert feedback on your performance.

The skin can be affected by various diseases, conditions, and injuries, from minor bacterial or fungal infections to serious skin cancer and severe burns that can be life-threatening.

For this Case Study Assignment, you will work with a patient who has a skin condition. You will create a list of possible diagnoses, assess treatment options, and develop a treatment plan.

To prepare:

– Review this week’s learning materials, considering how to assess, diagnose, and treat patients with skin conditions.
– Access i-Human through this week’s learning materials and review the case study for this week. Think about what health information you need from the patient.
– Consider which physical exams and diagnostic tests are appropriate to gather more information about the patient’s condition.
– Reflect on how the results of these exams and tests would help make a diagnosis.
– Identify three to five possible conditions that could be part of the patient’s diagnosis.
– Consider the patient’s diagnosis and clinical guidelines that support it.
– Develop a treatment plan for the patient, including health promotion and patient education for individuals with skin conditions.

Assignment:

As you interact with this week’s i-Human patient, complete the assigned case study. For guidance on using i-Human, refer to the i-Human Graduate Programs Help link within the i-Human platform.

NRNP_6531_Week2_Assignment_Rubric:

HPI statement:
– Novice: Poorly written HPI statement with incomplete ideas and sentences, lacking basic history-taking skills.
– Competent: Well-written HPI statement but may miss 1-2 key components from the history.
– Proficient: Clearly written HPI statement with comprehensive information gathering from case questions, covering all critical components.

History:
– Novice: Incomplete history missing 3 or more aspects of the OLDCARTS critical to the patient’s diagnosis.
– Competent: Fairly complete history covering most requirements but may miss 1-2 aspects of OLDCARTS critical to the patient’s diagnosis.
– Proficient: Complete history covering all critical components of a focus exam, including all aspects of OLDCARTS.

Physical Exam:
– Novice: Incomplete physical examination, may be missing 3 or more key exam findings critical to the patient’s diagnosis.
– Competent: Fairly complete physical examination but may miss 1-2 key exam findings critical to the patient’s diagnosis.
– Proficient: Complete physical examination covering all critical components of a focus exam.

Testing:
– Novice: Includes 3 or more inappropriate exams or tests, may include contraindicated testing.
– Competent: Tests ordered are generally appropriate, may include 1-2 unnecessary exams or tests.
– Proficient: Tests ordered are appropriate for the patient and cost-effective.

Differential Diagnosis Summary:
– Novice: Primary diagnosis may be incorrect. Differential diagnosis list is too brief and inconclusive, may miss 3 or more critical components.
– Competent: Correct primary diagnosis identified. Well-written differential diagnoses, may miss 1-2 critical components. Priority list may be out of order.
– Proficient: Primary diagnosis identified. Clearly written differential diagnoses.

Plan for Patient:
– Novice: Poorly written plan, may miss 3 or more key issues critical to the patient’s diagnosis.
– Competent: Well-written plan but may miss 1-2 key issues critical to the patient’s diagnosis.
– Proficient: Clearly written plan covering all critical components for the patient’s final diagnosis.

Exercises:
– Novice: Correctly answered 0-69% of the clinical questions.
– Competent: Correctly answered 70-89% of the clinical questions.
– Proficient: Correctly answered 90-100% of the clinical questions.

Total Points: 100