IHUMAN PRACTICE CASE STUDY PEN - PERPETUAL ASEME Perpetual Anita Aseme IHUMAN Practice Case Study: Mr. Marvin Webster NURS5342 Advanced Health Assessment LaMicha Hogan, APRN, MSN FNP-BC... Molly Toon, DNP, APRN, CPNP-PC Date January 25, 2021 CC: 18 y/o M Chief complaint is a short 1-2 statement or word phrase from patient and should be listed in “quotes” “I feel awful, I’m exhausted. I have body aches and just feel really tired.” HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts Mr. Webster, an 18-yr-old male presented to the clinic with complaints of persistent dry cough, sore throat, right ear pain, fatigue, headache, and myalgia. He reports he has exercised induced asthma which has been latent and did not receive his annual flu vaccine. Onset: Most symptoms appeared 1-2 days ago Location: Mostly throat, Headache and Ear Duration: Every day and symptoms have persisted since onset. Character: He reports 2/10 severity of ear pain which is non-radiating, and sharp. Sore throat of 6-8/10 severity which is non radiating and feels like a razor cut. Headache is mild and just annoying. Aggravating/alleviating factors: Sore throat is aggravated by cough and swallowing. Related symptoms: Fatigue and myalgia with onset of other symptoms 1-2 days ago. Denies exposure to any sick people. Treatments: He has tried ibuprofen for pain Significance: He feels exhausted and he is missing class PMHx child/adult illness/hospitalizations/immunizations Childhood exercised induced asthma with no recent exacerbations. No hospitalizations, trauma or other injuries Immunizations: States his immunizations are SurgHx type/when/why/complications Never for Surgical history. current for college. He has not received the Flu vaccine this year. FamHx Grandparents (if known)/Parents/siblings/children He has no knowledge of his grandparents medical history. Mother-age 58-Hypertension Father-age 57-Healthy SHx Tobacco/vaping/ETOH/illicit drug use/occupational/environmental/relationships Alcohol—Denies any recent alcohol intake, but occasionally drinks wine in the night after studying. Tobacco—Denies any history of smoking, vaping, or other tobacco use. Denies Recreational drug use. Relationships: Single Full-time student, not planning on working during the first semester. Denies any recent travel outside country in the past 2 weeks Reproductive Hx Female: Age of menarche/menstruation cycle duration/gravida para status/Childbirth hx/sexual hx and concerns/LMP/menopause Breast/cervical screening (if any) Male: Sexual hx and concerns/issues with fertility (if any)/Testicular or prostate screening (if applicable) Screening for STI’s (if applicable) Male patient not currently sexually active Allergies (Food, Drug, Environmental, etc.) List of Medications/supplements (prescription, OTC, complementary alternative therapies) Ibuprofen used occasionally for pain. Review of Systems: (ROS) Use this column to document the ROS below. General: Denies any weight gain or loss HEENT: Denies vision changes. Complaints of sore throat, cough, right ear pain and headache Pulmonary: Denies shortness of breath. Reports From the ROS: list/highlight the current symptoms/complaints to generate a list of pertinent “reported or denied” symptoms below: Pertinent Positive ROS: Reports headache; Sore throat that worsens with cough and swallowing, 6-8/10 pain scale; sharp ear pain that does not radiate to any part of the body rate scale of pain at 2/10. He feels exhausted and has aches and cough. CV: Denies any chest pain. GI: Denies nausea, vomiting, diarrhea or constipation. GU: No complaints of urinary problems MS: Complaint of myalgia Heme: No complaints of bleeding or bruising Lymph: Endocrine: No complaint of polyuria, polydipsia Derm: Denies any rash or lesion. Neuro: No complaints of tingling to Lower extremities Psych: Denies feeling hopeless and sad pains all over his body. Pertinent Negative ROS: Denies shortness of breath or wheezing and also denies chest pain. Physical Exam: (PE) Use this column to document the PE below. Vitals (HR/BP/RR/T/SpO2/Ht/Wt/BMI%) Temperature: 100.4 Pulse: 88 Blood pressure: 122/82 mmHg - Sitting Respiratory rate: 16 bpm SpO2: 98% on room air Weight 185 lbs. Height 6’0” BMI 25.1 General: HEENT: Normocephalic, head atraumatic, Pupils reactive, Right ear shows slightly red tympanic membrane, Bilateral red, From the PE: list/highlight the presence or absence of objective findings to generate a list of pertinent “(+) or (-)” symptoms below: Pertinent Positive PE findings: Right eat shows red tympanic membrane, bilateral red erythematous/edematous pharynx. Positive anterior cervical lymph nodes. Scattered fine crackles of lungs on auscultation. Pertinent Negative PE Findings: Negative for wheezing, Thoracic lymph node non palpable. Symmetrical respirations and no abnormal retractions erythematous, and edematous pharynx. Neck: Anterior cervical lymph nodes. Negative thyroid enlargement Pulm: Bilateral scattered fine crackles, Negative for wheezing, Thoracic lymph node non palpable, Symmetrical respirations, and no abnormal retractions. CV:HR 88. Normal heart sounds GI: Soft round and no tenderness. BS active X 4 GU: Normal genitalia, no tenderness or masses and no urethral discharge Neuro: Cranial nerves I-XII intact, Normal gait and posture MSK: ROM normal, equal bilaterally. Psych: No cognitive impairment Lab/Radiology or other Diagnostic data: Rapid Strep antigen detection test (RST/RADT) - Negative COVID – 19 PCR (swab) Complete blood count (CBC) – Normal except for slightly elevated WBC (11,500) Rapid influenza diagnostic test (RIDT) - Positive Problem Statement: Mr. Webster is a 22-year-old male presenting with flu-like symptoms for the past 1-2 days. He reports of non-radiating ear pain with a scale of 2/10 that is sharp as well as a sore throat with intensity of 6-8/10 which is aggravated by cough and swallowing. He also has a complaint of myalgia and fatigue. He has a medical history of asthma with no recent exacerbation, otherwise, PMH/Surgical HX/FH was reviewed and non-significant. Denies recreational drug use and tobacco use; he reports occasional wine. PE findings shows scattered fine crackles of the lungs, low grade fever, anterior cervical lymph nodes, and bilateral red erythematous/edematous pharynx. IHUMAN TOTAL CASE SCORES: #1: 74% List the differential diagnoses (Must not Miss/Leading/Alternate/Concluding) #2: 58% Based on patient’s age/risk factors, what preventive screening would be recommended at today’s or a future visit: Grade A Screening for High BP in adults 18 years and older HIV screening although not currently sexually active, he has been in the past. Grade B Screening for unhealthy drug use in adults 18 years and older *Include ICD 10 codes after each Must not Miss/Leading The myalgia, fatigue, low grade fever, nonproductive cough, ear pain and sore throat is more indicative of influenza as well as the positive Influenza PCR test. Influenza (J11.1) is the most conclusive diagnosis. Covid – 19 (U07.1) must be ruled out since there is a pandemic and the symptoms of cough and sore throat as well as the myalgia. Negative test rules out COVID-19 Group A Streptococcus pharyngitis (Strep throat) (B95.0) ruled out by negative strep antigen test. Community Acquired Pneumonia (CAP) (J18.9) – negative hypoxia and productive cough makes it a less like diagnosis. Alternate Asthma: although there is a medical history of asthma, it has been latent, and the physical examination did not show any wheezing. (ICD10data.com, 2021) *Case Study Template adapted from the following sources: NP H & P (ReNursing.edu, 2018) and IHuman Patients by Kaplan (2020) Reflective Thinking Exercises (start a new page) 1. History-Taking: Describe your history taking scores and strengths you identified when gathering data. What went well? Also, describe your challenges in gathering data and list areas of your personal needed improvement. Note any missed areas that could be safety issues/errors leading to missed or incorrect diagnosis. The history taking score for my final attempt was 70%. The History taking is overwhelming to me. Going through the available questions was difficult at first but with all the attempts I was able to identify where to locate various questions. It was difficult to really narrow down the questions that were pertinent to this patient. I exhausted the number of questions I could ask during one of the attempts. To do better in subsequent cases I need to limit my history to very targeted questions that is relevant to the patient’s complaints. 2. Physical Exam: Describe your physical exam scores and strengths you identified when performing selected exams on your patient. Did you perform an excessive amount of exam items? Did you miss any pertinent exam items identified in the case leading to diagnosis? Note any missed areas that could be safety issues/errors leading to missed or incorrect diagnosis. Physical exam was a bit more tolerable. The score for the last attempt was 82%. Although I was more confident, I found myself missing documentation for areas that required that I documented my findings. I will be more attentive in upcoming cases and also carefully review resources on how to perform certain assessments more accurately. 3. Evidence-based decision making: Discuss the evidence-based resource(s) utilized while seeing the patient. These can be your course readings/IHUMAN lessons/other course info as well as any external articles or supporting literature to help you gain a better understanding of categorizing possible diagnoses in your case. How did you use the symptoms/patient presentation, plus your exam findings, to formulate a differential diagnosis list? What specific feedback from previous case studies has your faculty identified that you plan to incorporate on future cases to avoid pitfalls in data gathering or decision making? What will you do differently to improve? The required text readings from S2D and Dain was very beneficial especially S2D with identifying differential diagnosis. Dain was helpful in identifying questions to ask and follow up questions in the history taking section. I also used previous information from pathophysiology and pharmacotherapeutics. The expert feedback from IHuman helped me to better formulate my diagnosis and put together my notes. References ICD10Data.com. 2021 ICD-10-CM Codes. https://www.icd10data.com/ICD10CM/Codes. [Show More]
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