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NR 602 case Study Ebony Gray week 1 case 1 NR 602 WEEK 1 CASE 1!!! Grading Rubric

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by

Liu
in

 

  1. 40% = History questions
  2. 30% = Physical exam
  3. 10% = Differential diagnosis list
  4. 10% = Ranking the differential diagnosis
  5. 10% = Lab test
  6. 0% = Science exercises
  7. 0% = Management plan – faculty scores this.

Case Help

HISTORY:

  • Patient interview reminder sheet – document in key findings
  • “Good Question” means you asked a required question

Step 1: Start by asking 2 open-ended patient-centric questions:

  1. How can I help you today?
  2. Any other symptoms or concerns?

Step 2: Obtain an HPI using “OLDCARTS”

  • O = Onset, circumstances surrounding start of symptom
  • L = Location, radiation
  • D = Duration
  • C = Characteristics (sharp, dull, cramping)
  • A = Aggravating
  • R = Relieving
  • T = Treatments
  • S = Severity

Step 3: PMH

  • No patient record – Obtain history
  • Have patient record – Update allergies, medications, OTC drugs

Step 4: FH

  • No patient record – Obtain history

Step 5: SH

  • No patient record – obtain history
  • Have patient record – Update if major changes in living situation, death of partner, loss of job, etc.

Step 6: ROS

  • Questions for systems not addressed in HPI
  • Choose ROS for the body systems you do not have information on. Use the large multipart questions

Physical Exam

  • Do those physical assessment maneuvers as needed
  • Choose ROS for those body systems you do not have information on. Use large multipart questions.

Assessment

  • Organize key findings list by selecting the MSAP (Most significant active problem).
  • Mark other findings as: related, unrelated, unknown, PMH/resolved.

Problem Statement

  • Short summary of patient’s presentation. Should contain:
    1. Demographic description,
    2. Chief complaint,
    3. Hx and PE key findings,
    4. Risk factors.
  • Keep it concise.

Differential Diagnosis

  • List disease you are considering Prior to ordering tests.

Tests:

  • Determine what tests are needed to rule in or rule out each diagnosis on authors corrected list.
  • Review authors corrected list of test results.

Final Diagnosis

  • Select a final diagnosis or diagnoses.

Treatment plan

  • Write a treatment plan following your instructors’ guidelines.

Gear head exercises

  • Complete exercises found throughout the case (look for the brain with gears icon in steps of the case)

Summary

  • Proceed all the way to the “Summary” tab.
  • Submit your case and press the “see evaluation” button to see your first evaluation.

Ebony Gray 25 y/o 5’6 (168cm) 140.0 lb (63.6kg) A&Ox4

Vital Signs

  • Temp: 37.1 (98.7)
  • Pulse: 78 bpm, rhythm: regular, strength: normal
  • BP L/arm 110/72, R/arm 110/72, assessment: normal, pulse pressure: normal
  • RR: 14 bpm, rhythm: regular, effort: unlabored
  • SpO2: 94%

CC: 25 y/o desires contraception

HISTORY:

Good Questions:

  • 2 Open-ended questions:
    1. How can I help you today?
    2. Any other symptoms or concerns?

HX Final Questions:

  • How can I help you today?