NR 511 Week 5 iHuman Virtual Patient Encounter Attempt 2792702 - Marta Hernandez

History Notecard by Lidia Aleman on case Marta Hernandez Use this worksheet to organize your thoughts before developing a differential diagnosis list. 1. Indicate key symptoms (Sx) you have identified from the history. Start with the patient's reason(s) for the encounter and add additional symptoms obtained from further questioning. 2. Characterize the attributes of each symptom using "OLDCARTS". Capture the details in the appropriate column and row. 3. Review your findings and consider possible diagnoses that may correlate with these symptoms. (Remember to consider the patient's age and risk factors.) Use your ideas to help guide your physical examination in the next section of the case. HPI Sx = Headache Sx = SxSxSxSx Nausea = = = = Onset 1 day ago early came on morning as HA got worse/1 day Location starts at left stomach temple but then spreads to whole head Duration 30 hours/More than a after day HA onset Characteristics Throbbing constantly Unsettling Aggravating Caffeine/Red wine eating food Relieving dark, quiet room not eating Timing / Minor HA (Tylenol)/ nothing Treatments Moderate HA no relief with medication but only with sleep in dark, quiet room Severity 8 out of 10/ starts acute gradually but then worsens Attempt: 2792702 Report generated on 6/17/2023, 2:58:42 PM America/Denver Management Plan by Lidia Aleman on case Marta Hernandez 1. Diagnostic test: Erythrocyte sedimentation rate (ESR), blood- 4mm/hr normal ESR Giant cell arteritis (GCA) is an inflammatory disease of the medium and large vessels that occurs in adults over 60 years old and can lead to complications of vision loss (Micieli & Kingston, 2019). Although this disease is often seen in older adults, it can be present in younger patients and can be benign (Micieli & Kingston, 2019). According to Micieli and Kingston (2019), headaches are the most common symptom occurring in more than two-thirds of patients with GCA. Therefore, ordering the ESR test can help to rule out the possible diagnosis of GCA in the patient. 2. Medications: Acetaminophen 325 mg 1-2 tablets PO every 4 to 6 hours, as needed for mild headaches (Prescribers' Digital Reference, 2023). Do not exceed more than 10 tablets per day or 4000 mg/day. Sumatriptan (Imitrex) 25mg 1 tablet PO once for a migraine. May repeat dose once after 2 hours if the first dose has not resolved the headache or if the headache returns after transient improvement; Max dose is 200mg/day (Prescribers' Digital Reference, 2023). According to Jenkins (2020), triptans are the first-line drugs and most selective against migraines as this drug class help patients with moderate-severe pain when simple analgesic medications have no effect. Zofran (ondansetron) 8mg 1 tablet PO every 8-12 hours, as needed for nausea (Prescribers' Digital Reference, 2023). Zofran can help relieve nausea in patients experiencing migraines. 3. Suggested consults/referrals: A referral to a neurologist would be critical if the patient’s headaches continue to persist and do not respond to standard or aggressive treatment (Mungoven et al., 2021). Migraines can interfere with the patient’s social, personal, and everyday life. 4.