NR 509 Week 6 iHuman Virtual Patient Encounter Attempt 3437569 - Kathleen Parks
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History Notecard by Lauren Stafford on case Kathleen Parks Use this to collect your thoughts to develop a differential diagnosis list. Step 1: Write symptoms (Sx) you have identified in the appropriate column and row. Step 2: Characterize the symptoms using "OLDCARTS" (ie., Onset, Location, Characteristics...etc) in the HPI section. Step 3: Record your thoughts in the space labeled "What this means". Is the disease acute or chronic? Infectious or other?... Timing/treatments Hx Categories Sx= Sx= Sx= Sx= Sx= Sx= CC Provided How can I help you? Any other symptoms? HPI Onset/events Location Duration Characteristics Aggravating Reliving Severity What this means Attempt: 3437569 Report generated on 2/15/2025, 7:36:34 PM America/Chicago Management Plan by Lauren Stafford on case Kathleen Parks Diagnostic Tests: No diagnostic tests were used, and no diagnostic tests are required at this time due to a normal neurological exam. Pharmacological Care: Ibuprofen 500 mg once a day Sumpatriptan, venlafaxine, topiramate and a beta blocker are all appropriate medications to prevent episodic migraines Provide neurology referral for further preventative care. Client Education: Recommend to keep a diary of the migraines and the symptoms that occur. It is important to have follow up evaluation on what is working regarding your medication regimen. There are specific symptoms that we look for. Nausea and vomiting are some of the more worrisome symptoms (Seung Jae Kim et al., 2023). Report these symptoms if they increase in frequency. Follow Up: Follow up in 6-8 weeks to establsih treatment efficacy. Go to ER for evaluation if headaches worsen or increase in pain. References: Seung Jae Kim, Hye Jeong Lee, Sue Hyun Lee, Cho, S., Kyung Min Kim, & Min Kyung Chu. (2023). Most bothersome symptom in migraine and probable migraine: A population-based study. PLOS ONE, 18(11), e0289729–e0289729. https://doi.org/10.1371/journal.pone.0289729 Attempt: 3437569 Report generated on 2/15/2025, 7:36:34 PM America/Chicago Social History Category Data entered by Lauren Stafford Social History Patient states that she occasionally has 2-3 glasses of wine a week. She occasionally smokes marijuana, and does not smoke tobacco products. Review of Systems Category Data entered by Lauren Stafford General Patient has no other significant health history other than the headaches. Integumentary / Breast Patient denies any itegumentary/breast history. HEENT / Neck Patient describes headaches as 8-10/10 on a pain scale, and they can last up to 15 hours. She describes the headaches as an intense throbbing. She states that she sees flashing lights and has spotty vision during the worst of the headaches. Cardiovascular Patient denies any cardiovascular medical history. Respiratory Patient denies any respiratory history. Gastrointestinal Patient denies any gastrointestinal history. Genitourinary Patient denies any genitourinary history, and has seen her OB/GYN in the last 6 months. Musculoskeletal Patient denies any musculoskeletal history, and denies any weakness in relation to her headaches. Allergic / Immunologic Patient has no known allergies. Endocrine Patient denies any endocrine history. Hematologic / Lymphatic Patient denies any hematologic/lymphatic history. No recent labs have been drawn. Neurologic Patient as previously mentioned as a 10 year history of headaches. She describes
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