NR 509 Week 6 iHuman Virtual Patient Encounter Attempt 3700373 - Bebe Babbitt
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History Notecard by Jerricka McCullum 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=headache Sx=nausea Sx=vomiting Sx= Sx= Sx= CC Provided How can I help you? Any other symptoms? HPI Onset/events Location head Duration Characteristics throbbing type sensation Aggravating Reliving Severity What this means Attempt: 3700373 Report generated on 10/12/2025, 11:55:33 PM America/Denver Management Plan by Jerricka McCullum on case Bebe Babbitt Diagnoses: Migraines with aura Plan: Case Summary: The patient is a 26-year-old female with a 10-year history of headaches, now presenting with worsening unilateral headaches over the past two months. These episodes occur every 1–2 weeks and last up to 15 hours. She reports associated symptoms including blurry vision, nausea, vomiting, photophobia, and phonophobia. The pain is described as a unilateral throbbing sensation, typically behind the left eye, and rated 8– 10 in intensity. She notes a correlation between headache onset and stress from graduate school and part-time work, as well as consumption of chocolate, red wine, and junk food. Physical examination revealed normal vital signs, intact range of motion, cranial nerves, and a normal neurological exam. The diagnosis is migraines with aura. Plan: Education will focus on migraine pathophysiology and management. The patient will be advised to maintain a headache diary to track frequency, duration, and potential triggers. She will be counseled on avoiding known triggers such as red wine, chocolate, and processed foods, and encouraged to stay hydrated. Education will also include the importance of adhering to prescribed treatment regimens and recognizing signs of medication-overuse headaches. Red flag symptoms will be reviewed, including thunderclap headaches, neck stiffness with fever, and uncontrollable vomiting. Pharmacologic treatment includes initiating naproxen 500 mg PO once for acute pain. Sumatriptan (Imitrex) 50 mg PO may be taken once daily, with a second dose permitted after two hours if symptoms persist, not to exceed 200 mg in 24 hours. Metoclopramide 10 mg PO every 6–8 hours may be used for nausea and vomiting, with a maximum daily dose of 45 mg. Referral to neurology will be placed for further evaluation and consideration of preventative therapy. Supportive care recommendations include maintaining adequate hydration, engaging in moderate to vigorous physical activity for 30–60 minutes at least 3–5 days per week, obtaining 8 hours of sleep nightly, and reducing intake of caffeinated beverages. Follow-up is scheduled in 6–8 weeks to assess treatment efficacy and make adjustments as needed. The patient is advised to return sooner if migraines persist despite abortive therapy, if headache characteristics change, or if frequency or severity increases. Emergent care should be sought for sudden onset of severe headache (“worst headache of life”), thunderclap headache, uncontrollable vomiting, or neck stiffness with
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