NR509 iHuman Virtual Patient Encounter – Neurologic Assessment

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Description

Preparing the Assignment

Follow these guidelines when completing each component of the assignment. Contact your course faculty if you have questions.

A. General Instructions

Remember This

For this week’s iHuman Virtual Encounter cases you will only get ONE attempt.

ATTENTION: Multiple practice attempts allow students the opportunity to review feedback from i-Human including documentation. Feedback is to be used to guide improvement on subsequent attempts for the practice case. It is never acceptable for students to submit feedback verbatim (or almost verbatim) and/or documentation in the EHR. Copying – Using the work of others is a violation of CU’s Academic Integrity Policy. Violations will be fully investigated by faculty and administration.

Access iHuman by clicking the link on the following page. Click the blue bar to launch the activity in a new browser window. The case does not need to be completed in one sitting; it can be re-entered at the same point at a later time.

All graded documentation, including the management plan, must be completed within the iHuman platform. Follow the iHuman Documentation GuideLinks to an external site. to complete your client’s electronic health record (EHR) and management plan. Use current APA Style Standards to format citations and references in the management plan and reflection. Use https://apastyle.apa.org/Links to an external site. and APA Academic WriterLinks to an external site. for formatting and grammar assistance.

B. Include the following sections (detailed criteria listed below and in the Grading Rubric)

Complete the following components in the iHuman Virtual Patient Encounter for the required case addressing the neurologic system.

1. Focused Health History
   1. Complete a focused health history. Scores are automatically calculated within the iHuman platform when the health history is submitted.
2. Focused Physical Exam
   1. Complete a focused physical exam. Scores are automatically calculated within the iHuman platform when the health history is submitted.
3. EHR Documentation (Subjective Data): Document the history of present illness (HPI) and focused review of systems (ROS). Documentation must be:
   1. accurate
   2. detailed
   3. written using professional terminology
   4. pertinent to the chief complaint
   5. includes subjective findings only
4. EHR Documentation (Objective Data): Document physical exam findings. Documentation must be:
   1. accurate
   2. detailed
   3. written using professional terminology
   4. pertinent to the chief complaint
   5. include objective findings only
5. Key Findings/Most Significant Active Problem: Document key findings from the history and physical exam in the Assessment tab of the case.
   1. Identify the most significant active problem (MSAP) and the relation of other key findings to the MSAP
6. Problem Statement: Document a brief, accurate problem statement using professional language. Include the following components:
   1. name or initials, age
   2. chief complaint
   3. positive and negative subjective findings
   4. positive and negative objective findings
7. Management Plan: Use the expert diagnosis provided to create a pertinent comprehensive evidence-based management plan. If a specific component of the management plan is not warranted (i.e., no referrals are appropriate for the virtual patient) document that no intervention is warranted. Include the following components:
   1. diagnostic tests
   2. medications: type a specific prescription for each medication, including over-the-counter medications
   3. suggested consults/referrals
   4. client education
   5. follow-up, including time interval and specific symptomatology to prompt a sooner return
   6. cite at least one relevant scholarly source and provide rationale for interventions as defined by program expectations
   7. Click ”Submit” once the case is complete. Use this guide to download the Performance Overview ReportLinks to an external site..
8. Reflection: Download this worksheetLinks to an external site. One rule is to always include “the worst-case scenario” in your differential diagnosis and make sure you have ruled out this possibility based on your findings and patient assessment. Your goal is to minimize the risk of missing unusual or infrequent conditions such as meningococcal meningitis, bacterial endocarditis, pulmonary embolus, or subdural hematoma that are particularly ominous.Address the following question:  What are the “red flags” in this case? Based on your pertinent key findings, what is “the worst-case scenario”? What lessons did you learn from this case that you can apply to your future professional practice? Include the following components:
   1. type 150-300 words in a Microsoft Word document
   2. demonstrate clinical judgment appropriate to the virtual patient scenario
   3. cite at least one relevant scholarly source as defined by program expectations
   4. communicate with minimal errors in English grammar, spelling, syntax, and punctuation

Submission

Submit both the Performance Overview Report and reflection document to the Week 6 dropbox.

SOLUTION

What are the “red flags” in this case?

In the case presented, there are several “red flags” that may indicate a more serious underlying condition. These include the sudden onset of a unilateral, throbbing headache accompanied by nausea, photophobia, and phonophobia. These symptoms, along with the recent increase in stress, decrease in sleep, and disrupted eating habits, could indicate a more severe condition such as meningitis or subarachnoid hemorrhage. According to a review article by MacGregor (2019), a high level of suspicion and a detailed clinical evaluation are essential in the evaluation of headache patients, particularly those with “red flag” symptoms such as those seen in this case. The article emphasizes…

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