Week 2: Kaylee Hales Derm iHuman Case Study
In the EMR section of the case, document the History of Present Illness (HPI) using the LOCATES or OLDCARTS Mnemonic. Begin with age, race, and gender, followed by a paragraph detailing the seven attributes of the principal symptom. Include any relevant historical information impacting the differential diagnosis.
Example: Kaylee Hales, a 34-year-old African American female, presents with a headache that started three days ago. She describes the pain as pounding, with pressure around the eyes and temples. Associated symptoms include nausea, vomiting, photophobia, and phonophobia. The pain occurs after prolonged computer use, light exacerbates it, and Aleve provides partial relief, resulting in a severity rating of 7/10.
Plan:
- Additional labs or diagnostic tests: Consider necessary tests, noting that some may require insurance authorization, e.g., MRI.
- Consults: Specify referrals to specialists or therapists and outline orders for a direct hospital admit if required.
- Therapeutic modalities: Detail pharmacological and nonpharmacological management, including medications, dosages, and durations.
- Health Promotion: Address relevant risk factors and preventive health screening, recommending appropriate immunizations.
- Patient education: Communicate diagnosis and treatment plan to patient and family members.
- Disposition/follow-up instructions: Clearly state when to follow up in clinic, seek earlier appointments, or go to the ER. Indicate specialist or therapist referrals and suggest alternative facilities if needed.
References: Provide a minimum of three scholarly references supporting the plan, excluding general patient education websites.
Assignment: i-Human Case Study: Evaluating and Managing Integumentary Conditions
As part of this week’s learning, utilize i-Human to interact with virtual patients and enhance patient-assessment and diagnostic-reasoning skills. For the assigned case study, focus on integumentary conditions, formulating a differential diagnosis, evaluating treatment options, and developing an appropriate treatment plan, considering health promotion and patient education. Follow the provided rubric for guidance during the interaction.
