Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Referral/Consults: Neurologist if the headaches persists after 4 weeks ophtalmologist Rationale/Citation If tina headaches and neck pain persist she needs to follow with a neurologist. Tina needs a comprehensive dilated eye exam, so the ophtalmolosgist will dilated her pupils so a better view of the inside of the eye is available. And then he might perform a fluorescein angiography (pictures of the inside of the eye) Corcóstegui, B., Durán, S., González-Albarrán, M. O., Hernández, C., Ruiz-Moreno, J. M., Salvador, J., … Simó, R. (2017). Update on Diagnosis and Treatment of Diabetic Retinopathy: A Consensus Guideline of the Working Group of Ocular Health (Spanish Society of Diabetes and Spanish Vitreous and Retina Society). Journal of ophthalmology , 2017 , 8234186. doi:10.1155/2017/8234186 Education: Patient was instructed to be cautioned when taking robaxin because it Rationale/Citation Patient needs to understand and
can cause drowsiness and dizziness. As well robaxin can impair mental status, so it needs to be used with caution. Patient was instructed as well if the signs and symptoms persist to go to the ER. Tina was instructed to report any changes in the level of consiousines, if she is unable to maintaine balance, if she develop double vision or confusion to go the near emergency room. follow the education given to be able to have a better outcome. Tina needs to know when to come to the ER and report worsening symptoms, or if they become worse. Follow Up: Indicate when patient should return to clinic and provide detailed instructions indicating if the patient should return sooner than scheduled or seek attention elsewhere. Tina was instructed to come back to the clinic in 3 weeks As well she needs to follow with the ophtamologist. Rationale/Citation It is important for the provider to see Tina in 3 weeks to see if the medications are helping her with the headaches and the neck pain, if not she will need to be refer to neurologist to get a deep and more complex treatment. References Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct APA 6th edition formatting. Crain Ian, Hoskin Justin, Al-Hasan Yazan, Zieman Glynnis, Cardenas Javie (Dec 2018) Early prophylactic treatment reduces development of chronic post traumatic headache after concussion. (23 Supplement 1) S29; DOI: 10.1212/01.wnl.0000550646.79759.e1 Defrin R. (2014). Chronic post-traumatic headache: clinical findings and possible mechanisms. The Journal of manual & manipulative therapy , 22 (1), 36–44. doi:10.1179/2042618613Y.0000000053
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- Fall '15
- Headaches, Tina, Medical diagnosis, Headache