NR 509 Week 6 iHuman Virtual Patient Encounter Attempt 3507966 - Bebe Babbitt
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History Notecard by Alana Scorzo on case Bebe Babbitt 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: 3507966 Report generated on 4/7/2025, 7:05:17 PM America/New_York Management Plan by Alana Scorzo on case Bebe Babbitt Migraines with Aura: Diagnostic Tests: N/A CMP/CBC- none on file. not necessary at this time but can be used as baseline in future. Medications: Sumatriptan (Imitrex) 25mg PO Once. For Migraines. If pain dose not subside in 2 hours after initial dose, take another full dose. Do not exceed 200mg in 24 hours. -- Triptans are used for moderate/severe migraines with aura. Best results occur when taken early, at the onset of pain or aura- whichever comes first. (Medlineplus, 2024) Metoclopramide (Reglan) 10mg PO Q6 PRN. For nausea associated with migraines. DO not exceed 45mg in 24 hours -- Used as supportive care Suggested consults/referrals: Neurology Consult to follow if pt adheres to treatment plan and migrines are not improving. Client education: Discuss potential triggers like stress at work or school, red wine, chocolate, and junk food. Provid education regarding the importance of avoiding triggers or limiting them. Adequate sleep and hydration may prevent migraines. (Mayans et al., 2018) Talk to patient about keeping a migraine diary until the next follow-up visit to assess the frequency, intensity of migraines, and the effectivenes and frequency of the use of sumatriptan. Talk to your provider about stopping sumatriptan, if considering becoming pregnant. The use of sumatriptan is contraindicated with pregnancy. (Medlineplus, 2024) Regarding Sumatriptan, talk to your provider if you are experiencing any side effects like flushing, tingling, drowsiness, weakness, dizziness, muscle cramps. Seek medical treatment immediately if you were experiencing shortness of breath, slow to difficult speech, fitness, weakness, or numbness in an extremity or sudden stomach pain.(Medlineplus, 2024) Follow-up: Schedule a follow up visit with the office for 6 to 8 weeks after initiating treatment. Medication may need to be adjusted based on reassessment. Call the provider if migraines persist after taking treatment as prescribed dose. Do not exceed 200 mg of sumatriptan in 24 hours. (Medlineplus, 2024) If you experience a headache that is worse than normal, and seems to be "the worst headache of your life", thunderclap in nature, associated with neck pain and stiffness, fever, or uncontrollable vomiting, seek care at the closest emergency department. (Mayans et al., 2018) Electronic Health Record by Alana Scorzo on case Bebe Babbitt History of Present Illness Category Data entered by Alana Scorzo Reason for Encounter increased frequency of severe headaches over
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