Electronic Health Record Provider-to-Provider Communication

Smith, Morgan
MRN: #######
Female, 14 y.o. 4/4/2003
Weight: 48.5 kg (106 lb 14.8 oz)
Phone: (585) 555-5555
PCP: Brown, Mary, MD
Status: Active
Morgan Smith
Date: 11/27/2017 at 10:56 a.m.
Marina R. Connolly, MD → Lesley L. Jones, MD
Cc: Kayla Hunt, PsyD; C. Grayson, PNP

I had the pleasure of seeing your patient, Morgan Smith, in the Golisano Children's Hospital at Strong Child Neurology Headache Clinic today for evaluation of her headaches. Morgan was accompanied by her mother who contributed to the history.While you are familiar with this patient, please allow me to review their history for my edification and records. As you know, Morgan is a 14 year old, right- handed female with a history of cyclic vomiting that began at age 5 and has now transitioned to a more classic migraine presentation. She was relatively symptom free until one year ago when she began to complain of headaches. The headaches began to worsen over the past 6 months after sustaining a concussion while playing volleyball.

Onset of symptoms: Cyclic vomiting from age 5 through 10. She was followed by Child Neurology and Pediatric GI during that time. Her episodes were managed prophylactically with Cyproheptadine and acutely with Ondansetron and Benadryl. She has had several ED amissions due to dehydration during her more intense episodes. She presents today with gradually increasing frequency and intensity headaches over the past 6 months. She has had recent complaints of stomachache with burning sensation. She has had multiple visits to the school nurse for prn analgesics for headache management. The school nurse frequently sends her home instead of allowing her to rest in the office and then go back to class.

Frequency, Timing, and Duration of Headaches: Headaches occurring 2-3 days per week at random times and last from 3-4 hours up to all day until she goes to bed at nightl. Intensity: Majority of her headaches have an intensity level reported at 7-9 on a scale of 1-10. She doesn't feel that she has ever really had a 10/10 headache. Most headaches cause her to cease activity and are now interfering with school attendance and ability to participate in activities, sports, and social events with friends.

Description/Quality of pain: Unilateral, right-sided temporal throbbing pain. She also endorses sharp pain and feeling of fullness behind her right eye.

Prodrome/Aura: Endorses feeling irritable the day prior to headache onset. She states that she experiences left-sided numbness in her lips and tongue approximately 10 minutes prior to headache onset at times. She also experiences left-handed tingling in her fingers, occasionally has difficulty "getting the words out" just prior to headache onset.

Associated symptoms: Nausea, no vomiting, photophobia, phonophobia.

History of previous head trauma/concussion: Concussion approximately 6 months ago while playing volleyball-spike ball to the head. Headaches began to worsen since.

Triggers: Sleep deprivation, stress, overscheduling, possibly dehydration.

Menstrual cycle: normal monthly cycle.

Appetite: Healthy diet, but skips breakfast frequently during the school week. Irregular eating pattern due to school/activities schedule. No significant changes in weight.

Hydration: Primarily drinks water. Caffeine intake 2-3 times/week (iced coffee beverages). She doesn't carry a water bottle at school. She reports drinking approximately 24 oz/day. She also drinks energy drinks 2-3 times/week in the afternoons prior to her activities. She reports that the energy drinks have vitamins in them and believes them to be healthy.

Sleep pattern: Goes to bed at 10:30 pm each night during school year. She has late nights trying to get her school work completed after her numerous extracurricular activities that take place in the evening. It often takes her 1 to 1-1/2 hours to fall asleep. She states that she lies in bed and just can't fall asleep as she is thinking of all that she needs to do the next day. She awakens at 6am for school.

Mood: Escalating level of anxiety due to feeling overwhelmed, pressured, and overscheduled. Occasionally feels "panic" and worries that this will happen to her when she is at school. This has led to some occasional school absences.

School/extracurricular activity days missed due to headache: 7-8 full days since September, some late arrivals or early departures. Increased frequency of absences over the last 6-9 months. She also admits to using her mother's prescription for Tylenol with Codeine (mom unaware). She also tries cool compresses when she has a headache.

Current Acute Headache Medication/Treatments: Using Excedrin migraine on an almost daily basis. She takes been taking 1-2 doses/day for the past 3 months.

Current Preventative Headache Medication: none

Previous Headache Evaluation (Imaging, Labs, Other Testing): none

Date of last Ophthalmologic Exam: two months ago-dilated exam-reported as normal.

Other specialists involved in Morgan's care: n/a

Past Medical History: Cyclic vomiting syndrome, anxiety, seasonal allergies

Social History: 9th grade in high school. She has excellent grades (high honor roll/high achiever). She participates in softball and volleyball (school and travel), drama, singing, dance, and plays guitar. She also goes to an after school homework program which is used to provide a structured, quiet, proctored environment in which to complete academic work and receive extra help if needed. She lives with mom, dad, and younger sister.

Family History:
Migraine: mom, MGM, maternal aunt.
Fainting episodes: mom
Anxiety: mom, dad, MGM.

Current Medications:
Excedrin migraine

Allergies (drug, environmental, food or latex): none reported

Review of Systems:
A 10 point review of systems was completed and was negative except for what was mentioned in the HPI.
No reported history of seizures, incoordination, behavior change, nocturnal or morning headaches with emesis, or headache that is worse in recumbent position or with cough/strain.

Focal Neurological Symptoms:

Visual: Negative for reduced vision, decreased visual fields, sudden vision loss, or diplopia.
Vestibular: Negative for loss of coordination or imbalance.
Auditory: Negative for difficulty hearing or tinnitus.
Motor: Negative for paralysis, unilateral weakness, loss of muscle control, increased muscle tone, loss of muscle tone, or involuntary movements.
Sensory: Negative for paresthesias, numbness or changes in sensation.
Mental Status: Negative for confusion, disorientation
Speech/Swallow: Negative for aphasia, dysarthria, poor enunciation, poor understanding of speech, impaired ability to read or to understand writing. No reports of swallowing difficulty, or choking.

Physical Exam

General Appearance: Well-appearing, well-groomed, no acute distress
Lungs: clear to auscultation
Cardiac: regular rate and rhythm, no murmurs
Extremities: No deformities noted
Skin: No significant birthmarks noted
Neurologic Examination:
Mental Status: Awake, alert and oriented. Attention was normal. Speech was intelligible.
Language: Appropriate for age
Cranial Nerves:
II: Visual fields full to confrontation
III, IV and VI: EOMs full in all directions of gaze. No nystagmus.
V: No facial sensory loss.
VII: No weakness of facial muscles.
VIII: Hearing intact.
IX and X: Palate elevates symmetrically.
XI: Normal shoulder shrug
XII: Tongue bulk and strength normal
Motor: Normal tone and bulk throughout. 5/5 strength throughout all major muscle groups tested. Good finger to nose coordination.
Involuntary movements: None noted
Muscle stretch reflexes: 2+, symmetric throughout with flexor plantar responses
Sensation: Intact to touch in all extremities
Coordination: No appendicular or truncal ataxia.
Station/Gait: Casual gait shows normal base. Able to walk on heels and toes and perform tandem walk well forward and back without difficulty.

Assessment:

Morgan is a 14-year old female with a history of headaches and associated symptoms consistent with a diagnosis of Migraine with Aura, Tension Type Headache, and Medication overuse headache. Additionally, she exhibits symptoms associated with anxiety/panic. Mom seems to over or misinterpret Morgan's migraine symptoms due to her own history of migraine which often increases Morgan's anxiety level. SCARED rating scales completed and will be shared with psych provider. Mom very concerned and requesting imaging which is not indicated at this time.

Plan:

The exam and history make a structural brain abnormality, intracranial hypertension, or subacute bleed unlikely. Based on the history and exam, neurodiagnostic imaging is not necessary at this time.

  • Begin Amitriptyline 10 mg nightly for migraine prophylaxis
  • Begin Migrelief-1 tablet twice daily for migraine prophylaxis
  • Use Rizatriptan 10 mg at onset of migraine for acute management
  • Discontinue use of OTC analgesics for 2 weeks; counsel to expect possible withdrawal headache
  • Keep track of headaches in a calendar or log to identify possible triggers or patterns.
  • Maintain routine patterns of sleeping, eating, and exercise.
  • Eat small, healthy meals and snacks throughout the day. Try not to allow more than 3 hours without a snack. Do not skip meals!
  • Avoid over-scheduling. Consider decreasing number of extracurricular activities throughout the week to lighten the load.
  • Referral to psych for Cognitive Behavioral Therapy (CBT) to promote relaxation, anxiety reduction, coping with pain.
  • Educate school nurse about managing headaches at school without sending Morgan home. Provide School Headache Management plan which includes medication consent that allows Morgan to receive prn medication at school.
  • Consider alternative and complementary therapies that do not involve the use of medication. They may help to relieve symptoms and prevent migraines. Possible treatment options include biofeedback, yoga, meditation, aromatherapy, cell phone apps for meditation, mood tracking, and mindfulness.

Thank you again for involving me in the care of this patient. More than 50% of this 60 minute visit was spent on face to face discussion of the diagnosis and treatment plan, teaching, counseling and coordination of care.

Please feel free to call or email me any time with questions or concerns about the treatment plan.

Electronically signed by @ME@ @NOW@ @TD@

Division of Child Neurology
Golisano Children's Hospital at Strong
601 Elmwood Avenue, Box 631
Rochester, New York 14642
585-275-2808-phone
585-275-3683-fax

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