NR 509 Week 6 iHuman Virtual Patient Encounter Attempt 3028447 - Jessica Walbertz
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History Notecard by Christi Magdos on case Jessica Walbertz Use this worksheet to organize your thoughts before developing a differential diagnosis list. 1. Indicate key symptoms (Sx) you have identified from the history. Start with the patient's reason(s) for the encounter and add additional symptoms obtained from further questioning. 2. Characterize the attributes of each symptom using "OLDCARTS". Capture the details in the appropriate column and row. 3. Review your findings and consider possible diagnoses that may correlate with these symptoms. (Remember to consider the patient's age and risk factors.) Use your ideas to help guide your physical examination in the next section of the case. HPI Sx = Sx = Sx = Sx = Sx = Sx = Onset Location Duration Characteristics Aggravating Relieving Timing / Treatments Severity Attempt: 3028447 Report generated on 2/14/2024, 2:57:31 PM America/Chicago Management Plan by Christi Magdos on case Jessica Walbertz Management: Diagnostic Studies: -ESR: 4mm/hr. Normal result (Hollier, 2021) -Can consider CT, MRI, and MRA which are reserved for patients with neurological deficits, sudden onset of headache, or a change in the frequency/occurrence of headache (Hollier, 2021). Medications: -Naproxen/Naprosyn: 500mg tablet orally every 12 hours as needed for pain; max daily dose 1,500mg/day. -Sumatriptan/Imitrex: 50mg tablet. take 1 tablet by mouth once with fluids, may repeat dose after 2 hours; Max dose 200mg by mouth every 24 hours. (Hollier, 2021) Nonpharmacological Management: Application of ice, cool compress to the head/face/scalp/neck, dark room, quiet atmosphere, cognitive behavioral therapy, and relaxation techniques (Hollier, 2021). Referrals/Consultations: -none are needed at this time. -can consider a referral to a Neurologist for severe headaches or lack of response to therapy (Hollier, 2021). -will need to be referred for compromised immunity, caused, for example, by HIV or immunosuppressive drugs age under 20 years, and a history of malignancy a history of malignancy known to metastasize to the brain vomiting without other obvious cause. A substantial change in the characteristics of their headache, worsening headache with fever, sudden-onset headache reaching maximum intensity within 5 minutes, and new-onset neurological deficit (Team, 2023). Education: -Migraines can be triggered by many different things such as wine, increase in stress, fatigue, lack of sleep, skipping meals, lack of exercise -For individuals who suffer from frequent headaches, keep a diary that records important information about duration, the location and intensity, what you did and ate before it came on, and your response to any treatment. This can be used to determine potential triggers to avoid. -getting proper rest, "set consistent bedtimes and wake times; sleep only as long as you need to feel rested; avoid caffeine, alcohol, and smoking before bed; do not look at your phone or other devices right before bed" (UpToDate,2023). -balanced diet around the same time each day -education on the indications, use, and risks of medications prescribed. (UpToDate, 2023) Follow-Up Care: -Return to the clinic or emergency room if the headache is unresolved after 72 hours, it becomes more severe or varies from the normal/usual pattern (Hollier, 2021). References -Hollier,
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