iHuman Assessment Jessia Walbertz, Exams of Nursing

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iHuman Assessment Jessia Walbertz

History Feedback Below you will see the strategy for selecting the "required" questions in this patient encounter using the OLD-CARTS mnemonic for the HPI. Reason for Encounter Start with open-ended patient-centric questions. @ Asked X Not asked Graded Approach Orientation Orientation Orientation Orientation CC Sx Assoc Sx Assoc Sx Assoc Sx Assoc Sx Assoc Sx Assoc Sx Assoc Sx Question What is your name? Where are you? What time is it? What happened? How can | help you today? Is there any stiffness in your neck? Have you had any seizures? Do you have high blood pressure? Do you feel confused at times? Have you been having fevers? Do you have any other symptoms or concerns we should discuss? Do you have any sensitivity to light? Response Jessica A Walbertz In the doctor's office. ..oriented to time when asked.. | have a headache that just won't go away. I've had this really bad headache since yesterday morning and it hasn't gotten any better. Not really. Never in my life, as far as | know. Not that anyone has ever told me about -- neither on or off the birth- control pill. Meaning, like, when | have a headache? No, nothing like that. No...I haven't been sick, just stressed. Yeah, | also feel a bit nauseated. Yes. That comes with my headaches. | just want to be ina dark room. Information Obtained Clinic Notes Characteristics Characteristics Characteristics Characteristics Characteristics Characteristics Characteristics Characteristics Characteristics Aggravating Relieving Does the headache awaken you from sleep? Does your headache come and go? Has there been any change in your headache over time? How quickly does your headache come on? Do any foods seem to bring the headaches on? Does your headache keep you from sleeping? Is there any pattern to when your headaches occur? Does your headache pulsate? Does your headache change with exercise? Does anything make your headache better or worse? Do your headaches improve when you drink caffeine? No, this one started when | was awake. I've never had one that has woken me up. Is that what you're asking? Once it starts it lasts quite a while, usually lasting more than a day. | think it's happening more often. It always starts gradually but then gets progressively worse. Sometimes | get headaches after drinking red wine. No. | can usually fall asleep if | can find a dark, quiet room. Some of my friends say they can get headaches with their periods, but they don't seem to be timed or linked to my menstrual cycle. So | would say no pattern | know about. Yes. It's been throbbing constantly. | wouldn't know. | can't even imagine going to the gym with this headache. | guess | have two types of headaches, the minor ones that seem to go away when | take acetaminophen and then the bad ones like the current headache. Acetaminophen doesn't really touch it. The only thing that seems to help is for me to lie down in bed in a dark, quiet room. No, just the opposite. Sometimes too much caffeine gives me a headache. | know this positively because one of my friends thought a strong cup of coffee would help, you know, the last time | had a headache like this, and boy was she wrong. It just made it so much worse. Timing/Treatments Timing/Treatments Timing/Treatments Timing/Treatments Timing/Treatments Timing/Treatments Timing/Treatments Severity Severity HPI HPI Do you have any awareness or warning symptoms that occur before the headache begins? What treatments have you had for your headache? Do you have headaches at night? Are you taking any medications for your symptoms? Do you have any symptoms that occur at the same time as your headache? How often do you have headaches like this? How often are you nauseous or vomiting? ls this the worst headache of your life? How severe (1-10 scale) is your headache? Have you had any contact with other sick people? Does anyone in your family have a headache? Usually not and | don't remember anything unusual this time. But last summer | had a scary episode. | started seeing flashes of light and having problems seeing in certain directions. This lasted about 20 minutes and then the headache started. It has never happened again, but the headache---where it started and how it spread felt similar to the one | have now, but | didn't have any visual stuff this time. I've been taking two acetaminophen tablets every four hours since the headache started. They don't specifically come at night. Just Tylenol. | feel nauseous and loud noises also bother me. | have had headaches like this for a long time, but I'm getting them more often... like about every four to six weeks and they are worse, more painful. Only when | have a really bad headache. Hard to say. It feels pretty bad, but | had one like it about a year ago. Pretty bad right now: 8 of 10. Not that | know of. My sister has frequent headaches, and | remember when | was young my mom having days where she would want to lie down alone in a dark room. | assume those were haadarhac Review of Systems (ROS) Select the major body systems that have not been touched on during the interview process for the HPI. @ Asked X Not asked Graded Question Have you noticed any bruising, bleeding gums, nose bleeds, or other sites of increased bleeding? Do you have problems with heat or cold intolerance, increased thirst, increased sweating, frequent urination, or change in appetite? Do you have problems with dizziness, fainting, spinning room, seizures, weakness, numbness, tingling, or tremor? Do you have any problems with nervousness, depression, lack of interest, sadness, memory loss, or mood changes, or ever hear voices or see things that you know are not there? Do you have any problems with fatigue, difficulty sleeping, unintentional weight loss or gain, fevers, or night sweats? Do you experience chest pain discomfort or pressure; pain/pressure/dizziness with exertion or getting angry; palpitations; decreased exercise tolerance; or blue/cold fingers and toes? Do you experience shortness of breath, wheezing, difficulty catching your breath, chronic cough, or sputum production? Do you have problems with nausea, vomiting, constipation, diarrhea, coffee grounds in your vomit, dark tarry stool, bright red blood in your bowel movements, early satiety, or bloating? Da you have problems with muscle or joint pain, redness, swelling, muscle cramps, joint stiffness, joint swelling or redness, back pain, neck or shoulder pain, or hip pain? Response Wow, that all sounds bad. Don't have any of that. Nope. | haven't passed out or felt like dizzy or anything like that. No. Just that college weight gain from eating junk food and not exercising enough. | wish | had more time for some sleep... Nope Nope. Oh my gosh that's a long list. No bleeding from any end. Nope. Information Obtained Clinic Notes 1of1 Index of Exercises @ Correct X Missed € Incorrect Choice Yours Graded Recent history of head trauma. e Gradual onset of headache over a few hours. Worsening when standing up. re Headache awakens patient from sleep. x ‘No response to acetaminophen 325 mg. ‘Scoring: Your score will be 0 if you select more than the number of correct choices. Case Problem Statement Feedback Discussion Red flags for secondary-headache syndrome include the following: + Recent history of head trauma + Headache awakens patient from sleep + Acute onset of headache over a few minutes’ period + Headaches beginning after age 50 + Headaches increasing in frequency and severity New-onset headache in a patient with risk factors for HIV infection or cancer Signs of systemic illness Focal neurologic signs other than typical aura Papilledema ‘See: Clinch RC. Evaluation of acute headaches in adults. Jessica Walbertz is a 22-year-old college student who presents with the complaint of a left-temporal headache that progressed over 30 hours to a throbbing (8/10) headache involving her entire head. She describes associated symptoms of photophobia, phonophobia, and nausea. Acetaminophen and rest had no effect which is different from her typical headaches. PMH is significant for a history of similar headaches over an unspecified number of years; a "scary" one last summer presented with "missing vision" and visual "flashes" lasting for 20 minutes, followed by a headache similar to her current one. Her headaches like this now occur every 4-6 weeks. Recent stressors include: academic, relationship break-up, and poor sleep and eating patterns. FH is significant for sister and mother with similar headaches. Meds include BCP. perform ocular motor test © You performed the simulation correctly. © Your documentation was correct. pulse oe You performed the simulation correctly. e You documented rate, rhythm, and strength correctly. reflexes - deep tendon o You performed the simulation correctly. reflexes - plantar/Babinski (L5/S1) e You performed the simulation correctly. respiration © You documented rate, rhythm, and effort correctly. sensory tests (light touch, pain, position, temperature, vibration) e Apattern of sensory abnormalities may elucidate the headache etiology. o For example, the presence of scalp or upper-extremity paresthesia and/or numbness may help to differentiate a cervicogenic headache. + Spo, temperature test strength A patient's muscular effort is graded from 0 to 5 using the Medical Research Council (MRC) scale: e Grade 5: Muscle contracts normally against full resistance. e Grade 4: Muscle strength is reduced but muscle contraction can still move joint against resistance. e Grade 3: Muscle strength is further reduced such that the joint can be moved only against gravity with the examiner's resistance completely removed. As an example, the elbow can be moved from full extension to full flexion starting with the arm hanging down at the side. e Grade 2: Muscle can move only if the resistance of gravity is removed. As an example, the elbow can be fully flexed only if the arm is maintained in a horizontal plane. e Grade 1: Only a trace or flicker of movement is seen or felt in the muscle or fasciculations are observed in the muscle. e Grade 0: No movement is observed. See: Medical Research Council (MRC) scale for muscle strength « test visual acuity The complete eye examination is considered part of the general physical exam and includes the following components: ¢ Visual acuity ¢ Pupillary reaction « Visual fields « Eye movements ¢ Funduscopic examination Several underlying mechanisms may contribute to acute changes in visual acuity: Vascular « Neurologic ¢ Inflammatory + Mechanical ® Not Required, Not Inappropriate * auscultate heart You performed the simulation correctly. You documented assessment correctly. « auscultate lungs You performed the simulation correctly. You documented left lung and right lung correctly. * cognitive status Your documentation was correct. « height « weight X Missed * administer gross pain stimulus e You administered a pain stimulus to a conscious patient. * orthostatic blood pressure (BP) e Yau documented systolic/diastolic as 140/84 and it should have been 124/82. e You performed the simulation correctly. Diagnosis Feedback Migraine headache is a clinical diagnosis that is based on a compatible history, lack of neurologic physical findings and at least 6 attacks that fulfill the following criteria: 1. Headaches lasting 4-72 hours 2. Headaches with at least 2 of the following characteristics: a) unilateral location, b) pulsating quality, c) moderate or severe pain intensity, d) aggravation or caused by avoidance of routine physical activity 3. During a headache the patient has at least one of the following associated symptoms: a) nausea, vomiting or both, b) photophobia and phonophobia Ms. Walbertz's presentation is typical for a migraine (she describes 3 attacks---but states she has had others) but a more complete history would be needed to see if she meets the threshold for 5 attacks. Ms. Walbertz does relate headaches that do respond to acetaminophen and are most likely tension headaches. This patient's history is not consistent with cluster headaches as a cluster headache would come and go multiple times throughout a single day. Giant cell arteritis would be highly atypical at her age and she denied any visual problems. Meningitis is generally associated with a more toxic presentation of fever and neck stiffness, which she did not have. Note: Neuroimaging (head CT) in patients with headaches would only be ordered if there were some neurologic or mental status findings that would warrant the need to rule out one of the following processes: brain tumor, subarachnoid hemorrhage, subdural hematoma, and venous sinus thrombosis. 1oi2 Index of Exercises Feedback @ Correct XMissed € Incorrect Choice Yours Graded ccuesi Discussion Migraine. Tension headache. In a patient with the "worst headache" of his or her life, itis important to keep in mind the Subarachnoid hemorthage e ‘must-not-miss diagnoses that could cause worse, if not catastrophic, outcomes i missed at the initial encounter. Regardless of the given patient's circumstances and presentation, itis Meningitis. e essential to keep in mind these causes of the worst headache of one's life: Cluster headache. Reversible cerebral vasoconstriction syndrome. x ¢, Guberachnokd hemermage Scoring: Your score will be 0 if you select more than the number of correct choices. + Reversible cerebral vasoconstriction syndrome @Corect XMissed € Incorrect Choice Yours Graded , ' Discussion Normal funduscopic examination. e Equal and normal motor examination. « Anormal neurologic examination is always a pertinent negative finding in the evaluation of Normal visual acuity any headache. But, in the context of a patient presenting with the "worst headache" of his/her lite, the following findings are very helpful in decreasing concern for meningitis or Lack of nuchal rigidity. e subarachnoid hemorrhage: Symmetric smile, c Normal mental status. x + Normal funduscopic examination; .., without evidence of papilledema + Lack of nuchal rigidity; along with absence of fever ‘Scoring: Your score will be 0 it you select more than the number of correct choices. + Normal mental status; note that some individuals with subarachnoid hemorrhage will have a normal mental status at initial presentation Plan Feedback The first-line management of Ms. Walbertz's migraine headache includes the following steps: + Advise patient regarding risk factors and awareness of migraine triggers Review OTC measures Prescribe sumatriptan, a serotonin-receptor agonist (triptan), as migraine-abortive therapy Provide antiemetic for use, if needed Follow-up in six weeks for review of medication efficacy; sooner, as needed, for nonresponse to initial treatment Discussion Management of common migraine should always begin with a discussion regarding risk factors and migraine triggers. Stress should be placed on the following preventive measures: + Regular meals » Regular exercise + Regular sleep and wake schedules + Avoidance of excessive caffeine intake Acute migraine headaches can initially be managed with over-the-counter analgesics such as aspirin, acetaminophen, ibuprofen, naproxen, and combinations of any of these agents with caffeine. More severe migraines may require the use of triptan medications to abort and/or prevent episodes. If nausea is a prominent symptom, antiemetics may be helpful in combination with other medications. Patients with frequently occurring migraines, or migraines that significantly interfere with daily life, are good candidates for prophylactic migraine medications. There are multiple classes of medications used for this purpose, including beta-blockers, tricyclic antidepressants and antiepileptic drugs. Patients with intractable headaches should be referred to tertiary-care headache centers or to a headache specialist. Regarding the use of oral contraceptive in women with migraine: "The newest combined oral contraceptive formulations are generally well tolerated in migraine without aura, and the majority of migraine without aura sufferers do not show any problems with their use; nevertheless, the last International Classification of Headache Disorders [2005] identifies at least two entities evidently related to the use of combined oral contraceptives: exogenous hormone-induced headache and estrogen-withdrawal headache." Source: Allais, et al. Oral contraceptives in migraine. + Nausea and/or vomiting + Photophobia and phonophobia E. Not attributed to any other disorder Migraine is felt to be a neurovascular disorder, involving both central nervous system and vascular structures; thereby, explaining the wide range of clinical symptoms. Red flags for secondary headaches (SNOOP —T): + Systemic symptoms or secondary risk factors: fever, weight loss; known cancer, HIV, immunosuppression, or thrombotic risks + Neurologic symptoms or abnormal signs: confusion, impaired alertness or consciousness, diplopia, vertigo, etc. * Onset: sudden; abrupt or split-second, or progressively worsening + Older: new-onset, progressively worsening headache, especially in middle-age individuals age 50 and older (giant cell arteritis) + Previous headache history: new, fundamentally different headache; i.e., significant change in frequency, severity, or clinical features * Triggered headache: provoked by Valsalva maneuver, exertion, or sexual intercourse Patient disposition Ms. Walbertz's headache was effectively treated with sumatriptan and ibuprofen. She was able to resume work on her paper, turned it in on time, and received a good grade. She continues to have one headache a month; however, she reports that her symptoms are much more tolerable since she began using sumatriptan at the first subjective indication of a migraine headache. Diagnosis Feedback Migraine headache is a clinical diagnosis that is based on a compatible history, lack of neurologic physical findings and at least 5 attacks that fulfill the following criteria: 1. Headaches lasting 4-72 hours 2. Headaches with at least 2 of the following characteristics: a) unilateral location, b) pulsating quality, c) moderate ar severe pain intensity, d) aggravation or caused by avoidance of routine physical activity 3. During a headache the patient has at least one of the following associated symptoms: a) nausea, vomiting or both, b) photophobia and phonophobia Ms. Walbertz's presentation is typical for a migraine (she describes 3 attacks---but states she has had others) but a more complete history would be needed to see if she meets the threshold for 5 attacks. Ms. Walbertz does relate headaches that do respond to acetaminophen and are most likely tension headaches. This patient's history is not consistent with cluster headaches as a cluster headache would come and go multiple times throughout a single day. Giant cell arteritis would be highly atypical at her age and she denied any visual problems. Meningitis is generally associated with a more toxic presentation of fever and neck stiffness, which she did not have Note: Neuroimaging (head CT) in patients with headaches would only be ordered if there were some neurologic or mental status findings that would warrant the need to rule out one of the following processes: brain tumor, subarachnoid hemorrhage, subdural hematoma, and venous sinus thrombosis. 1of2 Index of Exercises Feedback @ Correct X Missed € Incorrect Choice Yours Graded - | Discussion Migraine. Tension headache. In a patient with the "worst headache" of his or her life, itis important to keep in mind the Subarachnoid hemorthage. e ‘must-not-miss diagnoses that could cause worse, if nat catastrophic, outcomes if missed at 2 the initial encounter. Regardless of the given patient's circumstances and presentation, itis Meningitis, e essential to keep in mind these causes of the worst headache of one's life: Cluster headache. + Subarachnoid hemor: Reversible cerebral vasoconstriction syndrome. x I Meee remonhage Scoring: Your score will be 0 if you select more than the number of correct choices. + Reversible cerebral vasoconstriction syndrome @ Correct XMissed € Incorrect Choice Yours Graded - ; Discussion Normal funduscopic examination. e Equal and normal mator examination. € normal neurologic examination is always a pertinent negative finding in the evaluation of any headache. But, in the context of a patient presenting with the "worst headache" of his/her Normal visual acuity, life, the following findings are very helpful in decreasing concern for meningitis or Lack of nuchal rigidity. e subarachnoid hemorthage: Symmetric smile. c Normal fund out evidence of papi . tion; i.e., without Normal montal status x lormal funduscopie examination; i.e. without evidence of papilledema + Lack of nuchal rigidity; along with absence of fever + Normal mental status; note that some individuals with subarachnoid hemorrhage will have anormal mental status at initial presentation Scoring: Your score will be 0 if you select more than the number of correct choices.