NursingStudyHub

NR 602 Week 5 iHuman Case 3: Grading Rubric

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  1. Step 1: Start by asking 2 open-ended patient-centric questions:Step 2: Obtain an HPI using “OLDCARTS”Step 3: PMHStep 4: FHStep 5: SHStep 6: ROS
    • Patient Interview Reminder Sheet: Document in key findings.
    • “Good Question” means you asked a required question.
    1. How can I help you today?
    2. Any other symptoms or concerns?
    • O = Onset; Circumstances surrounding the start of the symptom.
    • L = Location, radiation.
    • D = Duration.
    • C = Characteristics (sharp, dull, cramping).
    • A = Aggravating factors.
    • R = Relieving factors.
    • T = Treatments.
    • S = Severity.
    • No patient record – Obtain history.
    • Have patient record – Update allergies, medications, OTC drugs.
    • No patient record – Obtain history.
    • No patient record – Obtain history.
    • Have patient record – Update if major changes in living situation, death of partner, loss of job, etc.
    • Questions for systems not addressed in HPI.
    • Choose ROS for the body systems you do not have information on. Use the large multipart questions.
  2. 30% = 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.
  3. 10% = Differential Diagnosis List
    • List diseases you are considering prior to ordering tests.
  4. 10% = Ranking the Differential Diagnosis
    • Rank the differential diagnoses in order of likelihood.
  5. 10% = Lab Test
    • Determine what tests are needed to rule in or rule out each diagnosis on the authors’ corrected list.
    • Review the authors’ corrected list of test results.
  6. 0% = Science Exercises
    • Complete exercises found throughout the case (look for the brain with gears icon in steps of the case).
  7. 0% = Management Plan – Faculty scores this.

Case Help

HISTORY:

  • Patient Interview Reminder Sheet: Document in key findings.
  • Step 1: Start by asking 2 open-ended patient-centric questions:Step 2: Obtain an HPI using “OLDCARTS”:Step 3: PMHStep 4: FHStep 5: SHStep 6: ROS
    1. How can I help you today?
    2. Any other symptoms or concerns?
    • O = Onset; Circumstances surrounding the start of the symptom.
    • L = Location, radiation.
    • D = Duration.
    • C = Characteristics (sharp, dull, cramping).
    • A = Aggravating factors.
    • R = Relieving factors.
    • T = Treatments.
    • S = Severity.
    • No patient record – Obtain history.
    • Have patient record – Update allergies, medications, OTC drugs.
    • No patient record – Obtain history.
    • No patient record – Obtain history.
    • Have patient record – Update if major changes in living situation, death of partner, loss of job, etc.
    • 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 diseases you are considering prior to ordering tests.

Tests:

  • Determine what tests are needed to rule in or rule out each diagnosis on the authors’ corrected list.
  • Review the 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.

Patient: Paisley Ward

  • 16 y/o 5’5 (165cm) 150.0lb (68.2kg) BMI 25 A&Ox4
  • Reason for encounter: Cough and SOB

Vital Signs:

  • Temp: 37.0 (98.6)
  • Pulse: 88 bpm, rhythm: regular, strength: normal
  • BP L/arm: 112/82, R/arm: 114/80, assessment: normal, pulse pressure: normal
  • RR: 26 bpm, rhythm: regular, effort: unlabored
  • SpO2: 94%

3 yr ago visit:

  • Reason: For Physical examination
  • Psych: Stress at home with financial situation of family. No anxiety or SI
  • PMH: Eczema: uses moisturizer daily, no flares for several years.
  • Hosp/Surg: Normal birth, full term, no medical problems. No major accidents or injuries. No surgeries.