NRNP – 6531 Kaylee Hales Derm case study


The following information is to be included in your i-Human cases:

HPI: You will type this in the EMR section of the case (NOT the problem statement)

This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. This is for subjective findings. Use LOCATES or OLDCARTS Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. Include any pertinent history information that might impact the differential diagnosis formulation. If the CC was “headache,” the LOCATES for the HPI would include the following information:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Plan: Type the information regarding each of the following sections into the i-Human Plan section of your case. You must address each of the 6 topics. For example, if you will not be consulting anyone then you must write “no consults indicated”. Each section of the plan is worth 5 points to total 30 points.

Additional labs or diagnostic tests: Additional laboratory and diagnostic tests may be necessary to establish or evaluate a condition. Some tests, such as MRI, may require prior authorization from the patient’s insurance carrier.

Consults: referrals to specialists, therapists (physical, occupational), counselors, or other professionals. If you are sending to hospital, what orders would you write for a direct admit?

Therapeutic modalities: pharmacological and nonpharmacological management. Give specific medications, dosing and duration. Include anticipated therapeutic modalities/symptomatic treatment for patients if they are sent to ED or directly admitted.

Health Promotion: Address risk factors as appropriate. Consider age-appropriate preventive health screening. What immunizations do they need?

Patient education: Explanations and advice given to patient and family members about diagnosis and treatment plan.

Disposition/follow-up instructions: include when to follow up in clinic, follow up sooner, or go to ER. When should they be seen by a specialist or therapist. When the patient is to return sooner, and when to go to another facility such as the emergency department, urgent care center, specialist or therapist.

Finally, be sure to include a minimum of 3 timely, scholarly references, that proves this plan and follows current standards of care. The course text may NOT be used as a reference. The references must be professional and not general patient education websites.

Assignment: i-Human Case Study: Evaluating and Managing Integumentary Conditions
This course will require you to complete a series of case studies using the i-Human software application. The i-Human Patients (IHP) Case Player enables you to interact with virtual patients for the purpose of learning patient-assessment and diagnostic-reasoning skills. With IHP, you will be able to independently interview, examine, diagnose, and treat virtual patients and receive expert feedback on your performance.
Photo Credit: RFBSIP / Adobe Stock
The integumentary system is susceptible to a variety of diseases, conditions, and injuries, ranging from the bothersome but relatively innocuous bacterial or fungal infections that are categorized as disorders to skin cancer and severe burns, which can be life-threatening.

For this Case Study Assignment, you will examine your first case study and work with a patient with an integumentary condition. You will formulate a differential diagnosis, evaluate treatment options, and then create an appropriate treatment plan for the patient.

To prepare:

Review this week’s Learning Resources. Consider how to assess, diagnose, and treat patients with integumentary conditions.
Access i-Human from this week’s Learning Resources and review this week’s i-Human case study. Based on the provided patient information, think about the health history you would need to collect from the patient.
Consider what physical exams and diagnostic tests would be most appropriate to gather more information about the patient’s condition.
Reflect on how the results would be used to make a diagnosis.
Identify three to five possible conditions that may be considered in a differential diagnosis for the patient.
Consider the patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.
Develop a treatment plan for the patient that includes health promotion and patient education strategies for patients with integumentary 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

Grid View
List View

Novice
Competent
Proficient
HPI statement

0 (0%) – 5 (5%)
Poorly written HPI statement. Incomplete ideas and sentences. Lacks basic history taking skills

6 (6%) – 10 (10%)
Well written HPI statement but may be missing 1-2 key components from the history

11 (11%) – 15 (15%)
Clearly written HPI statement with comprehensive information gathering from case questions.
History

0 (0%) – 6 (6%)
Incomplete history missing 3 or more aspects of the OLDCARDS critical to patient’s diagnosis.

7 (7%) – 8 (8%)
Fairly complete history covering most of the requirements but may be missing 1-2 aspects of OLDCARDS critical to patient’s diagnosis.

9 (9%) – 10 (10%)
Complete history covering all critical components of a focus exam. Includes all aspects of OLDCARDS
Physical Exam

0 (0%) – 6 (6%)
Incomplete physical examination. May be missing 3 or more key exam findings that are critical to patient’s diagnosis.

7 (7%) – 8 (8%)
Fairly complete physical examination but may be missing 1-2 key exam findings critical to patient’s diagnosis.

9 (9%) – 10 (10%)
Complete physical examination covering all critical components of a focus exam.
Testing

0 (0%) – 6 (6%)
Includes 3 or more inappropriate exams or tests. May include contraindicated testing.

7 (7%) – 8 (8%)
Tests ordered are generally apprropriate. May include 1-2 unnecessary exams or tests.

9 (9%) – 10 (10%)
Tests that are ordered are appropriate for patient and cost effective.
Differential Diagnosis Summary

0 (0%) – 9 (9%)
Primary diagnosis may be wrong.Differential diagnosis list too brief and inconclusive. May be missing 3 or more critical components.

10 (10%) – 14 (14%)
Correct primary diagnosis identified. Well written differential diagnoses. May be missing 1-2 critical components. Priority list may be out of order

15 (15%) – 20 (20%)
Primary diagnosis identified. Clearly written differential diagnoses.
Plan for patient

0 (0%) – 15 (15%)
Poorly written plan. May be missing 3 or more key issues that are critical to patient’s diagnosis.

16 (16%) – 25 (25%)
Well written plan but may be missing 1-2 key issues critical to patient’s diagnosis.

26 (26%) – 30 (30%)
Clearly written plan covering all critical components for patient’s final diagnosis.
Exercises

0 (0%) – 2 (2%)
Correctly answered 0-69% of the clinical questions.

3 (3%) – 4 (4%)
Correctly answered 70-89% of the clinical questions.

0 (0%) – 5 (5%)
Correctly answered 90-100% of the clinical questions.
Total Points: 100
Name: NRNP_6531_Week2_Assignment_Rubric

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