NR 509 Week 6 iHuman Virtual Patient Encounter Attempt 3515748 - Bebe Babbit
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History Notecard by Jihye Kim 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= CC Provided headache nausea/vomiting How can I help Further triggered by you? evaluation headache on chronic headache which became worse past few months Any Aura other zig- zaggy symptoms? light 30min before headache HPI Onset/events every 1-2 only occures months for with headaches past ten years then more frequent past few months Problem Statement by Jihye Kim on case Bebe Babbitt B.B. is a 26-year-old female presents to clinic due to chronic headache which has been worsening with its severity and increased frequency. Headache often accompanies with nausea and vomiting. The client reports aura with scintillating scotoma 30 minutes prior to its onset, headache last 15 hours with severity of 8-10, pain localized behind the left eye. Ibuprofen/Acetaminophen no longer effective. Headache trigged by lights, and sound. Resting in the dark room usually helps the client. Social factors are eating habit with excessive chocolate/snack, stress, lack of stress reduction measure such as exercise and leisure activities. Normal vital signs, other nurological assessments are intact, unremarkable. Attempt: 3515748 Report generated on 4/13/2025, 4:46:42 AM America/Los_Angeles Electronic Health Record by Jihye Kim on case Bebe Babbitt History of Present Illness Category Data entered by Jihye Kim Reason for Encounter B.B presents to the clinic due to worsening headaches every 1-2 weeks that lead to interfering with daily tasks such as school and work. Ibuprofen/Acetaminophen used to help but no longer effective due to having nausea/vomiting. Aura comes about 30minutes prior to the headache as zig- zagging lights and headache is located back of the left eye. History of present illness B.B 26-year-old female, with chronic headache for 10 years, last few months headache became worse in severity and occur more frequently. The client reports health status overall "good" other than the headache. Past Medical History Category Data entered by Jihye Kim Past Medical History N/A Hospitalizations / Surgeries N/A Medications Category Data entered by Jihye Kim Medications OTC Ibuprofen/acetaminophen (no longer in use) Allergies Category Data entered by Jihye Kim Allergies NKA Preventive Health Category Data entered by Jihye Kim Preventive health College required immunization is up to date. Covid/Annual vaccine received Family History Category Data entered by Jihye Kim Family History Mother has same type of migraine. Father/grandparents -unknown Physical Exams Category Data entered by Jihye Kim General A/OX4, Coherent speech, normal muscle tone and built. steady gait. Affect normal, appropriate cloth for weather, well-groomed. Skin intact HEENT / Neck Head: symmetrical, no infestation, atraumatic, no lesion Eyes: No periorbital swelling, discharge, redness visual acuity 20/20 Ear: no deformity, tympanic membrane translucent, non-bulging, pearly-gray,
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