NR 509 Week 6 iHuman Virtual Patient - Bebe_Babbitt
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History • Reason for encounter: more frequent severe headaches • History of present illness BB is 26 years old psychology grad school student who presents with worsening headaches over the past few months. She reports a 10 year history of episodic headaches, now occurring every 1-2 weeks with increased severity. Headaches are throbbing with 8-10/10 pain, located behind the left eye, lasting up to 15 hours to a whole day, and associated with nausea, vomiting, and photophobia. OTC acetaminophen or ibuprofen are no longer effective for headache. Headaches disrupt daily activities, and patient believes it is triggered by stress. Relief comes from resting in a dark, quiet room. Takes OTC Benadryl for sleep during finals. Denies fever, trauma, neck stiffness, vision loss, weakness, numbness, recent weight changes, depression, or menstrual irregularities. • General- Denies recent weight changes, weakness or fatigue. Denies fevers. • HEENT/Neck- Head- reports headaches, denies dizziness, lightheadedness. Denies any head trauma. Eyes- Reports seeing “flashing zig-zaggy lights” prior to headaches, does not wear glasses. Light sensitivity during headache episodes. Ears- denies ear pain, hearing difficulty. Nose- denies nasal stuffiness or discharge. Throat- denies sore throat Neck- denies neck stiffness or neck pain, denies any swollen glands. Denies difficulty swallowing. • Cardiovascular- denies chest pain, high blood pressure, palpitations • Respiratory- denies cough or shortness of breath • Gastrointestinal- nausea and vomiting associated with headaches • GU- denies frequency, urgency, incontinence. • Musculoskeletal/osteopathic – denies joint stiffness, muscle pain or tenderness. Denies any changes in posture or recent injury • Neurologic- reports seeing “flashing zig-zaggy lights” prior to headaches, denies changes in orientation, memory. Denies dizziness, weakness, numbness, tingling, seizures. • integumentary/breast- denies any rashes, lumps, sores, or changes in hair or nails. Denies any mole that has changed. • psychiatric- reports feeling stressed and mildly anxious with school and work. Stress triggers the headaches. denies feeling down, Physical exam • Bebe Babbitt • 26 years old • 122 lbs, BMI 19.7 • AO x 4 • Temp 36.9 C (98.5 F) oral • Pulse: 80 bpm, rhythm: regular, strength: normal • BP: left: 122/78, right: 118/80, assessment: normotensive, pulse pressure: normal • Respiration: 16 bpm, rhythm: regular, effort: unlabored • SpO2: 99% • General: alert, well-groomed, appears at stated age. Responds quickly to questions. Height: 5’6” (168 cm) Weight: 122 lbs. BMI: 19.7 Temp: 98.6 F oral Pulse: 80 bpm, rhythm: regular, strength: normal BP: left 122/78, right 118/80- normal with normal pulse pressure Respiration: 16 bpm, unlabored with regular rhythm SpO2: 99% on room air • HEENT/Neck: Head: Normocephalic, atraumatic. Face is symmetric with equal eye closure and smile. No temporal artery tenderness. Maxillary and frontal sinuses non-tender bilaterally. Eyes: visual acuity 20/20 bilaterally. No ptosis, lid lag, erythema or swelling noted. Conjunctiva pink, no discharge. Sclera white. PERRLA. Extraocular movements intact. Red reflex bilaterally. Optic disc sharp. No papilledema noted. Ears: external ears symmetric, no lesions, masses, or tenderness. No discharge or erythema noted. Auditory canal clear, no cerumen impaction, edema, or discharge. Tympanic membrane
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