Performance Overview for Patricia Plumer on case Lexie Newman, Exams of Nursing

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Performance Overview for Patricia Plumer on case

Lexie Newman

The following table summarizes your performance on each section of the case, whether you completed that section or not. Time spent: 2hr 20min 45sec Status: Submitted Case Section Stat us Your Score Time spent Performance Details Total Score 48% History Done 52% 37mi n 23se c 60 questions asked, 19 correct, 18 missed relative to the case's list Physical exams Done 87% 26mi n 20se c 55 exams performed, 33 correct, 0 partially correct, 6 missed relative to the case's list Key findings organizatio n Done 54sec 10 findings listed; 9 listed by the case Problem stateme nt Done 10mi n 47se c 88 words long; the case's was 114 words Differentials Done 33% 3min 52se c 8 items in the DDx, 1 correct, 2 missed relative to the case's list Differential s ranking Done 67% (lead/alt score) 100% (mus t not miss score ) 25sec Tests Done 100% 2min 8sec 6 tests ordered, 0 correct, 0 missed relative to the case's list Diagnosis Done 100% 8sec Manageme nt plan Done 3min 10se c 1203 words long; the case's was 498 words Exercises Done 100% (of scored items only) 23mi n 37se c 5 of 5 correct (of scored items only)

Problem Statement by Patricia Plumer on case Lexie Newman

This is a 12 y.o F presenting with symptoms of a throbbing 8/10 headache, neck stiffness, nausea without vomiting, and reports being "mentally foggy" since this morning. She has a history of a recent fall with a head injury, no LOC yesterday. She has a history of headaches and a family history of migraines in her mom and maternal grandmother. Exam reveals positive Romberg test, unstable single foot stand, slightly ataxic gait, mild ecchymosis on the right shoulder, and mild tenderness on paraspinal cervical muscles and sternocleidomastoid muscles.

Management Plan by Patricia Plumer on case Lexie Newman

1: Primary Diagnosis with ICD-10 code, rationale and resources. Primary: Concussion without LOC, initial encounter (S06.0X0A) - Concussions can be caused by direct trauma to the head, such as from falling, getting hit, or being in an accident. Loss of consciousness is not a requirement to diagnose concussion and is “reported to occur in less than 5% of sports related concussions” (Halstead et al, 2018). Primary: Sprain of ligaments of cervical spine (S13.4) - The patient will report a history of an injury that shows rapid acceleration and deceleration forces, such as a sports injury, and present with varied symptoms - neck pain and stiffness, interscapular pain, upper limb pain and paresthesis, occipital headache, visual disturbances (Bragg & Varacallo, 2022). Differential diagnoses with rationale and resources. 3-5 Ddx required Migraine, unspecified (G43.909) - Research shows that episodic migraines are characterized by moderate to “severe attacks of unilateral pulsating head pain, associated with photophobia, phonophobia, nausea and/or vomiting,” typically lasting 4–72 hours (Mungoven, Henderson, & Meylakh, 2021). Women are three times more likely to experience migraines compared to males. Spinal Cord Injury (S14.109A) - According to new research, “more than 90% of SCI cases are traumatic and caused by incidences such as traffic accidents, violence, sports or falls” (Alizadeh, Dyck, & Karimi- Abdolrezaee, 2019). Also, women are at a higher risk of having an SCI during their adolescence or 7th decade of life (Alizadeh, Dyck, & Karimi-Abdolrezaee, 2019). Other psychoactive substance abuse with intoxication, unspecified (F19.129) - Teenagers may engage in risky behaviors that can affect their mental or physical health. Symptoms of intoxication can range from impairment of simple tasks, slurred speech, nausea, vomiting, lack of coordination, impaired judgment, mood, and personality changes (Pasha et al, 2020).

2. Medications including OTC, dosage, pt. education, ancillary tests, referrals, and follow-up: MEDs - Start Acetaminophen 325 mg tablet - take 2 tablets PO q 6-8 hrs, prn headache or neck pain x7 days and Zofran 4 mg disintegrating tablet - take 1 tablet PO q 6 hrs, prn nausea x5 days. Can use ice packs for neck pain x15 min q 2-3 hrs. Pt. Education - Reassurance that most people recover quickly and completely following a mild concussion; however, symptoms can last for several weeks to months. Caregivers should closely monitor the child in the first 24 hours after injury and report any abnormalities to the provider. (Maaks et al, 2020). Caregiver educated on warning signs, when to bring the child to the office, or seek immediate emergency services. The patient should avoid any recreational activities that may result in a second head injury (eg, cycling, skateboarding, ice skating, or skiing) until resolved. Educated physical rest for 1-2 days after injury, then gradually return to noncontact, supervised activity - like doing simple chores around the home. Educate the patient and caregiver that the child may start engaging in light cognitive activities such as watching television, reading a book, family interaction, and homework for 10-15 min at a time, increasing as tolerated (Meehan & O’Brien. 2022). Educate the patient and caregiver that returning to school after a concussion may exacerbate symptoms and that academic accommodations can be given. The caregiver and patient were educated that she should not participate in any sports until cleared by a medical professional. Ancillary tests - If no improvement of symptoms in 1 week, or worsening of symptoms can consider a head and neck CT without contrast. Referrals - If symptoms do not improve 2 weeks after injury, refer to neurology or concussion clinic. Follow-up - RTC in 1 week for follow-up, sooner if symptoms worsen. Seek medical care immediately if the patient develops slurred speech, weakness, numbness or decreased coordination, significant nausea, repeated vomiting, headache worsens, seizures, or inability to wake up. Return to school in 2 days.
3. Completed Hx notes & Problem Statement in designated area (2.5 each area) a. Hx note completed in the appropriate area? Yes b. Problem statement completed in the appropriate area? Yes
4. Social Determinants of Health to consider, Health Promotion and Pt risk factors

Neighborhood and environment - She is an only child and lives with her mom and dad in their home. They have a cat in the home. No firearms in the home. She always wears her seatbelt in the car and helmet while bike riding. Social and community context - She has friends at school. She participates in extracurricular sports including cheerleading. No concerns of bullying. Health Promotion - Emphasize the importance of well child check-ups to ensure appropriate growth and development, as well as safety in this age group. Routine dental exams q6 months with good daily dental hygiene practices. Healthy diet - avoid caffeine and carbonated beverages, and spicy and greasy foods until nausea resolves. Gradually return to noncontact, supervised activity - chores around the house, walking in the neighborhood, ect. Injury prevention - wear proper fitting helmets when appropriate, wear seat belts in vehicles and safe-guard home to prevent falls. Encourage proper posture and body mechanics. Promote good sleep hygeine practices. Pt. Risk Factors - Her family history of migraines increases her risk since there is a genetic component. Her personal history of headaches also contributes. Cheerleading increases her risk of concussions, especially since she doesn’t wear a helmet or protective gear during this sport. According to the CDC, there were approximately 223,135 TBI-related hospitalizations in 2019 (2022). Teenagers may engage in risky behaviors that can affect their mental or physical health - alcohol, drugs, experimentation, and peer pressure. REFERENCES Alizadeh, A., Dyck, S. M., & Karimi-Abdolrezaee, S. (2019). Traumatic Spinal Cord Injury: An Overview of Pathophysiology, Models and Acute Injury Mechanisms. Frontiers in neurology, 10, 282. https://doi.org/ 10. 3389 /fneur. 2019. 00282 Bragg, K.J. & Varacallo, M. (Jan 2022). Cervical Sprain. [Updated 2022 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK 541016 / Centers for Disease Control and Prevention. (2020). CDC pediatric mTBI guidelines: Take action to improve the care of children with mTBI. Retrieved February 2, 2023, from https://www.cdc.gov/traumaticbraininjury/PediatricmTBIGuideline.html Halstead, M. E., Walter, K. D., Moffatt, K., LaBella, C. R., Brooks, M. A., Canty, G., Diamond, A. B., Hennrikus, W., Logan, K., Nemeth, B. A., Pengel, K. B., Peterson, A. R., & Stricker, P. R. (2018). Sport-Related Concussion in Children and Adolescents. Pediatrics, 142 ( 6 ). https://doi.org/ 10. 1542 /peds. 2018 - 3074 Maaks, D. G., Starr, N., Brady, M., Gaylord, N., Driessnack, M., & Duderstadt, K. (Eds.). (2020). Burns’ pediatric primary care (7th ed.). Elsevier. Meehan III, W. P., & O’Brien, M. J. (2022, November). Concussion in children and adolescents: Management. UpToDate. Retrieved February 2 , 2023 , from https://www.uptodate.com/contents/concussion-in-children-and- adolescents-management? search=concussion%20without%20loc %20treatment&source=search_result&selectedTitle=2~102&usage_type=defa Mungoven, T. J., Henderson, L. A., & Meylakh, N. (2021). Chronic Migraine Pathophysiology and Treatment: A Review of Current Perspectives. Frontiers in Pain Research, 2. https://doi.org/ 10. 3389 /fpain. 2021. 705276 Pasha, A. K., Chowdhury, A., Sadiq, S., Fairbanks, J., & Sinha, S. (2020). Substance use disorders: diagnosis and management for hospitalists. Journal of community hospital internal medicine perspectives, 10(2), 117–126. https://doi.org/ 10. 1080 / 20009666. 2020. 1742495

Electronic Health Record by Patricia Plumer on case

Lexie Newman

History of Present Illness

Category Data entered by Patricia Plumer Reason for Encounter headache History of present illness 12 y.o F presents with mother complaining of sudden onset headache this morning upon awakening. The pain is in the right frontal area. She describes the pain as throbbing and is 7-8/10 in severity. She states yesterday afternoon at cheerleading practice while on the top of the pyramid she fell and landed on her right side (shoulder, arm, and head). Associated symptoms are neck soreness, nauseous, and "mentally foggy". She denies loss of consciousness, vision changes, vomiting, gait abnormalities, and mood changes. Nothing seems to make the pain better or worse. The pain does not radiate and no treatments have been done.

Past Medical History

Category Data entered by Patricia Plumer Past Medical History Hospitalizations / Surgeries

Medications

Category Data entered by Patricia Plumer Medications

Allergies

Category Data entered by Patricia Plumer Allergies

Preventive Health

Category Data entered by Patricia Plumer Preventive health

Family History

Category Data entered by Patricia Plumer Family History