week 2
briala
WK2Assgn_Grey_K.pdf.pdf
Report generated on 3/13/2022, 11:45:29 PM America/Denver
Performance Overview for Kayla Grey on case Victoria Lewis V5.1 PC PL
The following table summarizes your performance on each section of the case, whether you completed that section or not.
Time spent: 8hr 45min 7sec Status: Submitted
Case Section Status Your Score
Time spent Performance Details
History Done 100% 3hr 11min 57sec
48 questions asked, 18 correct, 0 missed relative to the expert's list
Physical exams Done 69% 1hr 34min 2sec
24 exams performed, 3 correct, 2 missed relative to the expert's list
Key findings organization
Done 43min 31sec
7 findings listed; 6 listed by expert
Problem statement
Done 8min 32sec 70 words long; expert's was 77 words
Body system classification
Done 100% 13sec 1 of 1 correctly picked plus 0 extras
Differentials Done 40% 6min 42sec 5 items in the DDx, 2 correct, 3 missed relative to the expert's list
Differentials ranking
Done 100% (lead/alt score) 40% (must not miss score)
6min 11sec
Tests Done 100% 7min 22sec 1 test ordered, 0 correct, 0 missed relative to the expert's list
Diagnosis Done 100% 7sec
Management plan
Done 1hr 26min 3sec
233 words long; expert's was 99 words
Exercises Done 93% (of scored items only)
7min 10sec 4 of 5 correct (of scored items only) 1 partially correct
Attempt: 2282253
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https://www.coursehero.com/file/137891175/WK2AssgnGreyKpdf/
Report generated on 3/13/2022, 11:45:29 PM America/Denver
History Notecard by Kayla Grey on case Victoria Lewis V5.1 PC PL
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 =rash Sx =
Sx =
Sx =
Sx =
Sx =
Onset 36 hours
Location inner thighs and left inner forearm
Duration constant
Characteristics itching and tender
Aggravating none
Relieving none
Timing / Treatments
none
Severity unknown
Attempt: 2282253
This study source was downloaded by 100000848518627 from CourseHero.com on 06-08-2022 18:33:06 GMT -05:00
https://www.coursehero.com/file/137891175/WK2AssgnGreyKpdf/
Report generated on 3/13/2022, 11:45:29 PM America/Denver
Problem Statement by Kayla Grey on case Victoria Lewis V5.1 PC PL
V.L. is a 25 y/o Caucasian female that presents with a rash to bilateral inner thighs and inner left forearm x 36 hours that is itchy and becoming tender. This rash is erythematous with vesicles at various stages on inner thighs and erythematous with vesicles in a linear pattern on inner left forearm. This rash is most likely caused from contact with an allergen after a weekend trip to Napa.
Attempt: 2282253
This study source was downloaded by 100000848518627 from CourseHero.com on 06-08-2022 18:33:06 GMT -05:00
https://www.coursehero.com/file/137891175/WK2AssgnGreyKpdf/
Report generated on 3/13/2022, 11:45:29 PM America/Denver
Management Plan by Kayla Grey on case Victoria Lewis V5.1 PC PL
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 Medrol dose Pak 4mg as directed (24mg on day one, 20mg on day 2, 16mg 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.
Education: 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 should 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.
Attempt: 2282253
This study source was downloaded by 100000848518627 from CourseHero.com on 06-08-2022 18:33:06 GMT -05:00
https://www.coursehero.com/file/137891175/WK2AssgnGreyKpdf/
Electronic Medical Record by Kayla Grey on case Victoria Lewis V5.1 PC PL
History of Present Illness
Category Data entered by Kayla Grey
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
Category Data entered by Kayla Grey
Other active problems none
Medical, surgical, obstetric, hospitalizations
none
Medications
Category Data entered by Kayla Grey
Rx (medications) Birth Control Pill
Allergies
Category Data entered by Kayla Grey
Allergies Ceclor or Cefaclor - hives as a child
Preventive Health
Category Data entered by Kayla Grey
Preventive health Up to date on all immunizations Exercises regularly Normal American diet
This study source was downloaded by 100000848518627 from CourseHero.com on 06-08-2022 18:33:06 GMT -05:00
https://www.coursehero.com/file/137891175/WK2AssgnGreyKpdf/
Family History
Category Data entered by Kayla Grey
FHx (family history) Maternal grandfather died of CVD at age 81, grandmother alive age 88 prior heart attack, stent, and HTN Mother alive and well Father alive, HTN Brothers ages 35 and 32 alive and well sister age 21 alive and well
Social History
Category Data entered by Kayla Grey
SHx (social history) Has a Boyfriend monogamous relationship sexually active- BCP Reports occasional alcoholic drink Denies tobacco or drug use
Review of Systems
Category Data entered by Kayla Grey
General/Constitutional Generally well appearance. No fever or fatigue. No excessive weight gain or weight loss.
Skin/Breast Reports rash to bilateral upper thighs and inner left forearm. No other skin or breast changes.
HEENT & neck No problems with headaches, double or blurred vision, no eye redness, difficulty with night vision, problems hearing, ear pain, sinus problems, chronic sore throat, or difficulty swallowing. No problems with nasal drainage or congestion.
Cardiovascular No complaints.
Respiratory No cough, shortness of breath, or breathing difficulties
Abdomen/Gastrointestinal No complaints.
Genitourinary No complaints.
Musculoskeletal No problems with muscle or joint redness, swelling, muscle cramps, joint stiffness, joint swelling or redness, back pain, neck or shoulder pain or hip pain.
Allergic/Immunologic No complaints.
Lymphatic/Endocrine No complaints.
Hematologic No complaints.
Neurological No problems with dizziness, fainting, spinning room, seizures, weakenss, numness, tingling, or tremors.
Psychological No complaints.
This study source was downloaded by 100000848518627 from CourseHero.com on 06-08-2022 18:33:06 GMT -05:00
https://www.coursehero.com/file/137891175/WK2AssgnGreyKpdf/
Report generated on 3/13/2022, 11:45:29 PM America/Denver
Physical Exams
Category Data entered by Kayla Grey
General A/O x 4, dressed appropriately. BP 116/80, pulse 60BPM, respirations 13, Spo2 94%, and temperature 98.6
Skin/Breast Left forearm have itchy erythematous papules linear with vesicles. Bilateral inner upper thighs have raised erythematous papules with vesicles in various stages.
HEENT & neck Trachea midline, thyroid firm and normal size for age and gender, no nodules.
Cardiovascular PMI 5th ICS at the MCL. S1 and S2 noted. No murmurs, gallops, or rubs.
Respiratory Normal respirations, no shortness of breath or distress. No wheezing, crackles, or rales upon auscultation. No distention, scars, or masses noted.
Abdomen/Gastrointestinal Flat, symmetric, no scars, deformities, striae, or lesions. Hyperactive bowel sounds in all quadrants. No pain, tenderness, massess, or pulsations. No guarding or rebound tenderness, no hepatosplenomegaly, liver span normal, spleen not palpable.
Genitourinary N/A
Musculoskeletal No stiffness in joints. No swelling, deformities, cyanosis, clubbing or edema in extremeties.
Osteopathic N/A
Neurological N/A
Psychological N/A
Lymphatic/Endocrine No swollen lymphnodes.
Attempt: 2282253
This study source was downloaded by 100000848518627 from CourseHero.com on 06-08-2022 18:33:06 GMT -05:00
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