NR 509 Week 6 iHuman Virtual Patient Encounter Attempt 3638143 - Kathleen Parks
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History Notecard by s 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: 3638143 Report generated on 8/15/2025, 11:42:47 AM America/New_York Management Plan by on case Kathleen Parks Diagnostic Tests: Meeting the criteria for migraines and having a regular neurologic examination is all that is needed to diagnose a person with migraines (cite). Neuroimaging is only recommended if the neurologic examination is abnormal or the patient’s history shows red flags (cite). Medications: Sumatriptan 50mg tablet (Fisher et al., 2023). Take one tablet at the onset of migraine. May take a second 2 hours after the first dose if needed. Do not exceed 200mg within 24 hours. Quantity: 9 Refills: 0 Ondansetron 4 mg tablet . Take one tablet by mouth as needed for nausea and vomiting (Athavale et al., 2020). Quantity: 15 Refills: 0 Consults: None recommended Client education: Analgesic overuse can lead to medication overuse headaches and increase the risk of changing the type to chronic migraines over time (Tzankova et al., 2023). Be careful not to overuse Tylenol and ibuprofen when migraines occur. Triptans, acetaminophen, and non-steroidal anti-inflammatory drugs are the recommended first-line treatment for acute migraines (Tzankova et al., 2023). If this treatment does not work, we can increase the dosage to 100mg or change to a different class of medications (Tzankova et al., 2023). Ondansetron is useful and has fewer side effects than metoclopramide (Athavale et al., 2020). Serotonin antagonists such as ondansetron can cause QT prolongation, but rarely in oral dosing and below 8 mg daily (Athavale et al., 2020). Constipation may be an adverse effect of ondansetron. To manage this, consider eating a high fiber diet or taking stool softeners as needed (Athavale et al., 2020). Find a way to manage stress. Cognitive-behavioral therapy (CBT), relaxation techniques, exercise, etc., can be helpful in stress management (Hana Ali et al., 2024). Find an outlet that works for you to help reduce stress. Keep a migraine journal, note all migraines so we know how many you have a week. Notate what occurred before the migraine started, what helped relieve it, and how long it took to be managed. This will help guide treatment in the future. Follow up: Follow up in 4 weeks to see if these medications are helpful. If you find you need more than one tablet of sumatriptan (100 mg per migraine attack), inform the office to change the dosage. Electronic Health Record by on case Kathleen Parks History of Present Illness Category Data entered
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