NR 509 Week 6 iHuman Virtual Patient Encounter Attempt 3509274 - Bebe Babbitt
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History Notecard by Briayanna Nordwick 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=headacheSx=nauseaSx=vomitingS CC Provided none at this time How can I help reports bad occurs occurs with you? headache with headaches over past headaches few months, last one 1 wk ago Any nausea and other vomiting symptoms? HPI Onset/events possibly headache headache stress Location behind Left eye Duration up to 15 hrs throughout throughout headache headache Characteristics intense, throbbing Aggravating stress, light, headaches headaches noise Reliving lying down in when when dark, sleep headaches headaches resolve resolve on pain severity pain severity What this means Attempt: 3509274 Report generated on 4/13/2025, 4:59:12 PM America/Chicago Management Plan by Briayanna Nordwick on case Bebe Babbitt Diagnoses: Migraine with aura Pharmacologic Care: Naproxen 550mg PO once; can take a second dose 220-550 mg after 12 hrs. Max dose: 1,100mg per 24 hours Sumatriptan (Imitrex) 50mg PO once daily after onset of migraine and repeat once after waiting 2 hours without relief. Max dose: 200mg per 24hrs Metoclopramide (Reglan) 10mg PO q 6-8 hrs for nausea/vomiting. Max dose: 45mg per 24hrs (Sandor et al, 2021; Allias et al, 2023) Non-Pharmacologic/Supportive Care: Recommended acquiring refillable water bottle to ensure adequate hydration. Pursue stress relieving activities such as yoga, mindful meditation, deep breathing exercises, nature walks, listening to calming music. Physical daily activity 30-60 minutes each day, 3-5 days a week, research shows regular physical activity reduces stress. Ensure proper sleep quality, 8-10 hours per night for female adults recommended. A good before-bed routine helps promote quality sleep. (MacGregor, 2020) Patient Education: Educate importance of keeping a migraine log with symptoms. Provide education on avoiding triggers that may induce migraines, stayng hydrated and limiting intake of red wine, chocolate and junk food. Educate on red flags such as thunder-clap quality headache, neck pain/stiffness while having a fever, and uncontrollable vomiting. (Sandor et al, 2021) Referral: Neurology referral for further evaluation and preventative care (GBD 2023). Follow up: Schedule follow-up in 6 weeks to discuss the efficacy of current treatment plan and adjust as needed. Follow-up sooner if migraines persist despite treatment, change in headache occurs or if migraines continue to increase in frequency and/or severity. Seek emergent care for sudden onset "worst headache of my life", thunderclap headache symptoms, severe increase in pain, uncontrollable vomiting, neck pain/stiffness with fever, or any other concerning symptoms. (Allias et al, 2023; GBD 2023) References Allais, G., De Lorenzo, C., Airola, G., Rolando, S., Benedetto, C., & Schiapparelli, P. (2023). Framing and management of migraines in women: An expert opinion on challenges, current approaches, and future multidisciplinary perspectives. Journal of Clinical Medicine, 12(14), 4523. https://doi.org/10.3390/jcm12144523 GBD 2019
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