NRNP 6541 Primary Care of Adolescents and Children

Ihuman case:  History Of Present Illness (PUT IN IHUMAN!!!!)

 Andrew Chen is a 14-year-old male patient who presents to the clinic with his father with  complaints of pain, bruising, and swelling in his right ankle. He was playing in an intense  basketball game last night when he drove for a layup, in turn, stepping on his opponent’s foot and  falling. When he tried to get up, he had a pile of people on top of him. He had his trainer look at  his ankle and wrap it with an ACE wrap when it happened. He took the ACE wrap off last night  in order to shower and forgot to put it back on. He did ice and elevate his leg when he laid down.  He says the bruising and swelling have both increased since the initial injury. He is unable to  bear weight at this time due to the pain. He states the pain feels like someone is stabbing him at  times and rates it a 10/10 when he tries to move his foot. There are no associated signs as he only  complains of the pain from the ankle injury. He took Ibuprofen last night with some relief and  again this morning about an hour ago.

Management Plan Template– must include these headings: This section is worth 40 points.

1. Primary Diagnosis—10 points (all areas must be addressed)

a. What is the ICD-10 code (2 points):

b. What is your rationale for arriving at this primary diagnosis? You must integrate the pertinent finding and support your rationale with evidence-based literature (resources)(6 points)

c. Include CPT codes, and any procedural codes (such as nurse lab draws, vaccinations given, biopsies) (2 points):

2. Guidelines used to develop this primary diagnosis. 5 points

Here DO NOT write references.

In this section you need to write the clinical guidelines that you used to help you develop and create the plan for this diagnosis. For instance, for a kid with strep, students can follow the Centor Scoring for diagnosing strep and follow the IDSA guidelines for the management of strep.

1b and #2 should be two distinct answers.

3. Differential diagnoses (ddx)with rationale and resources. Minimum of 3-5 differentials (primary dx does not count as a differential). For well-child visit, if there are no other health issues, then differentials are not needed. 5 points



DDX #3-

4. Medications including OTC, dosage and education, additional ancillary

tests needed, referrals and follow up – 10 pts 

a. Medications (2 points)-

b. Pt. education (2 points)- –

c. Additional Ancillary (2 points)-

d. Referrals (2 points)- –

e. Follow-ups (2 points)- –

5. Problem Statement – 5 pts (simply write see problem statement written in iHuman section. Please note that the problem statement that I grade is the one written in the “Problem Statement” section within the iHuman.

6. Social Determinants of Health to consider, Health Promotion and Pt risk factors – 5 pts 

a. Social Determinants of Health (3 points)

b. Health Promotion (1 point)-

c. Pt. Risk Factors (1 point)—


Must have 3 and must show that it is cited within your text. Please understand that references provide the information necessary for readers to identify and retrieve each work  cited in the text. If your references are not cited within your text, then points will be deducted.

**NO MAYO CLINIC, no pt. education websites, CDC should only be for stats. REFERENCES must be peer-reviewed literature. Please utilize the Walden Library. Use primary sources.