NRNP – 6531 Week 2: Kaylee Hales Derm iHuman Case Study
HPI Instructions:
In the EMR section, not the problem statement, you must document the History of Present Illness (HPI). This is essential for patient care and coding. Start every HPI with age, race, and gender (e.g., 34-year-old AA male). Use the LOCATES or OLDCARTS mnemonics to ensure a thorough description. The HPI must be written in paragraph form and include pertinent historical information related to the patient’s differential diagnosis.
Example HPI for a Headache:
- Location: Head
- Onset: 3 days ago
- Character: Pounding, pressure around eyes and temples
- Associated symptoms: Nausea, vomiting, photophobia
- Timing: After working on a computer
- Exacerbating/Relieving factors: Light worsens, Aleve helps
- Severity: 7/10 pain scale
Plan:
Type the following six sections into the Plan part of i-Human:
- Additional Labs/Tests: List necessary tests (e.g., MRI, labs) and note insurance requirements if applicable.
- Consults: Include referrals to specialists or for hospital admission.
- Therapeutic Modalities: List pharmacologic and non-pharmacologic treatments, dosages, and therapy durations.
- Health Promotion: Address preventive screenings and necessary immunizations.
- Patient Education: Offer advice about diagnosis and treatment.
- Disposition/Follow-Up: Specify follow-up visits or urgent care instructions.
Each section of the plan contributes 5 points for a total of 30 points.
Assignment: i-Human Case Study: Evaluating and Managing Integumentary Conditions
Complete the case study using i-Human software. It simulates patient interactions for developing assessment and diagnostic skills. You’ll collect patient history, perform exams, and suggest a treatment plan, considering the following:
- Review this week’s learning resources to understand integumentary conditions.
- Access i-Human, study the provided patient information, and determine the relevant health history, exams, and diagnostic tests.
- Formulate a differential diagnosis with 3-5 conditions.
- Use clinical guidelines to support the diagnosis and treatment plan.
Assignment: As you complete the i-Human case study, submit the work per the course guidelines, referencing at least three scholarly sources (excluding the course textbook) to support your plan.
NRNP_6531_Week2_Assignment_Rubric
| Category | Novice (0-5%) | Competent (6-10%) | Proficient (11-15%) |
| HPI Statement | 0 (0%) – 5 (5%) Poorly written HPI, incomplete, lacks basic history-taking skills | 6 (6%) – 10 (10%) Well-written but missing 1-2 key components | 11 (11%) – 15 (15%) Clearly written, comprehensive information gathering |
| History | 0 (0%) – 6 (6%) Incomplete, missing 3+ aspects of OLDCARTS | 7 (7%) – 8 (8%) Fairly complete, missing 1-2 aspects | 9 (9%) – 10 (10%) Complete history covering all critical components |
| Physical Exam | 0 (0%) – 6 (6%) Incomplete, missing 3+ critical findings | 7 (7%) – 8 (8%) Fairly complete, missing 1-2 critical findings | 9 (9%) – 10 (10%) Complete exam covering all critical components |
| Testing | 0 (0%) – 6 (6%) 3+ inappropriate tests or contraindicated | 7 (7%) – 8 (8%) Appropriate but includes 1-2 unnecessary tests | 9 (9%) – 10 (10%) Appropriate and cost-effective testing |
| Differential Diagnosis | 0 (0%) – 9 (9%) Primary diagnosis incorrect, brief differential list | 10 (10%) – 14 (14%) Correct primary diagnosis but some missing priority issues | 15 (15%) – 20 (20%) Correct diagnosis with clear differential |
| Plan for Patient | 0 (0%) – 15 (15%) Poorly written, missing 3+ key issues | 16 (16%) – 25 (25%) Well-written but missing 1-2 key issues | 26 (26%) – 30 (30%) Clearly written, covers all critical issues |
| Exercises | 0 (0%) – 2 (2%) 0-69% correct answers | 3 (3%) – 4 (4%) 70-89% correct answers | 5 (5%) 90-100% correct answers |
| Total Points: 100 |
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