NURS 6512: Week 9 Assignment Use of AI in Evidence-Based Plan Management

NURS 6512: Week 9 Assignment Use of AI in Evidence-Based Plan Management

Assigned Case: Case Study 1: Headache and Vision Changes

List AI Tools Used: Chat GPT

SECTION 1: Differential Diagnoses (3–5 Required)

The case study: “Headache and Vision Changes” presents a patient whose chief complaint (CC) is bad (severe) headaches and sometimes seeing flashing lights. The 28-year-olf female asserts that she has had about 3 months of recurrent headaches that occurs 2-3 times a week. Therefore, based on the assessment and history she provides, the following are three differential diagnoses featuring subjective, objective, and pertinent history of findings in ruling out each diagnosis.

Differential Diagnosis 1: Migraine with Aura

Subjective findings

Supporting evidence:

The patient has recurring unilateral, and throbbing headaches that have persisted for 2-3 times a week, and last several hours. She reports having visual aura as illustrated by simmering lights and zigzag lines that precedes headaches. She reports related photophobia and mild nausea, stress and insomnia. She gets partial relief when she uses painkillers like ibuprofen.

The patient denies fever, neck stiffness, weakness, and speech difficulty. She also denies confusion, and loss of vision as well as any history of head trauma.

Objective Findings:

Objective findings that support the diagnosis include stable vital signs with BP 118/75 mmHg, HR 78 bpm, and afebrile, no papilledema with the cranial nerves II-IV being intact, normal motor strength present (5/5), and has normal reflexes (2+), normal gait, and lack of focal neurological deficits. Therefore, no abnormal neurological findings, no signs of increased intracranial pressure as well as meningeal signs.

Pertinent History

The patient’s mother has a history of migraine headaches while she suffers sleep deprivation as she sleeps only 5-6 hours. The patient also has occupational stress, and takes caffeine regularly.

Differential Diagnosis 2: Cluster Headache

Subjective Findings

The patient reports severe unilateral headaches as the initial supporting aspect of cluster headache. Cluster headaches typically present with unilateral periorbital pain as well as autonomic systems that include tearing, and nasal congestion. However, these are not consistent with the patient’s symptoms (Soriano, 2026). Again, findings like headaches that last several hours but not happening in clustered attacks, presence of visual aura, nausea, photophobia, and lack of nasal congestion, no tearing of the eye, and lack od eyelid drooping, as well as being female rule out this diagnosis (Haghdoost & Togha, 2022). Cluster headaches are more prevalent in males and not females. Additionally, the neurological examination is normal ruling out any possible cluster headaches.

No pertinent history to support the diagnosis since findings show positive maternal history of migraine, and the presence of typical migraine triggers that include stress, and sleep deprivation. The patient has no smoking history since cluster headaches have a robust link to smoking.

Diagnosis 3: Tension-Type Headache

Tension-type headache presents with bilateral and pressing or tightening although not throbbing pain. The pain is also milder but does not lead to nausea and being sensitive to light.

Subjective findings

The subjective findings that support this diagnosis include severe or frequent headaches, stress as a trigger, sleep deprivation, and use of ibuprofen. However, the findings from the assessment that rule out the diagnosis include having unilateral pain and not bilateral, throbbing pain, having nausea and photophobia, visual aura that precedes the headaches, and pain sensitive since she reports pain of 7/10.

The objective findings to support the diagnosis entails normal neurological assessment outcomes. Further, the patient does not report any scalp or peri-cranial muscle tenderness, has no muscle tension as observed during the examination (Soriano,2026).

Pertinent history characterized by high-work-associated stress, and insufficient sleep support the diagnosis. However, a positive family history of migraine, and having typical migraine triggers as well as related symptoms such as limited sleep support this diagnosis.

SECTION 2: Final Diagnosis

The final diagnosis for the patient is Migraine with Aura as supported by subjective, objective, and pertinent history findings that rule out other diagnoses based on evidence-based guidelines.

The subjective findings include the patient:

• Having a three-month history of recurrent unilateral and throbbing headaches
• Episodes happening 2-3 times a week
• Headaches that last several hours
• Experiencing visual aura that precedes headaches
• Related photophobia and mild nausea
• Trigger factors that include stress and deprived sleep as she only sleeps for 5-6 hours each night (Haghdoost & Togha, 2022)
• Having partial relief by using ibuprofen

Objective findings

• Normal vital signs
• Normal HEENT outcomes upon examination
• No papilledema
• Normal neurological examination
• No focal neurological deficits

Pertinent History

Pertinent history supports the diagnosis of migraine with aura as illustrated by

• Mother’s migraine history
• Being a young woman (28 years old), a population susceptible to migraine
• Chronic sleep deficit or deprivation
• High levels of occupational stress

No history of trauma, diabetes, hypertension, and associated conditions, which may suggest a secondary headache disorder However, this diagnosis is less likely since there are no red flag symptoms such as altered mental status, neurological deficits, neck stiffness.

Final Problem Statement

A 28-year-old female patient presents with head and vision change because of having bad headaches and sometimes seeing flashing lights. The patient reports having a 3-month history of recurrent unilateral and throbbing headaches that happens 2-3 times a week, and each lasts several hours. The patient reports that visual aura characterized by shimmering lights and zigzag lines precede the headaches. The headaches present with mild nausea, and photophobia. The patient also reports limited or inadequate sleep, and occupational-related stress. The patient denies having any history of chronic diseases like hypertension and diabetes, denies smoking, weakness, dizziness, and neck stiffness. Physical examination reveals normal aspects of body functioning without any neurological issues and no red-flag symptoms with the absence of weakness, dizziness, neck stiffness, and loss of vision. Pertinent history includes mother suffering from migraines, using caffeine as she drinks 2-3 cups of coffee daily, and working long hours as a graphic designer. Further, sleep deprivation triggers headaches. The overall clinical picture is most consistent with migraine with Aura.

SECTION 3: Evidence-Based Management Plan

 

Diagnostics

While the patient’s signs and symptoms are consistent with migraine with aura and does not warrant neuroimaging, it is essential to order for the following diagnostic procedures to rule out any differential diagnoses (Hervik et al., 2023).

Laboratory Tests

Routine laboratory tests are not recommended unless the history and examination of the patient suggest. However, a consideration of these tests may be necessary based on clinical guidelines and evidence-based practices:

• Complete blood count (CBC) to rule out anemia or infection
• Comprehensive metabolic panel (CMP) as the basis before recommending certain medications (Hervik et al., 2023)
• Pregnancy test before prescription of certain migraine medications
• The patient does not require any imaging since
• Neurological examination shows normal functioning of the body
• Signs and symptoms are consistent of migraine aura (Soriano, 2026)
• No red-flag aspects like fever, altered mental status and papilledema

An MRI brain or a CT scan (head) should be done if the patient develops neurological deficits, the characteristics of the headache significantly change or any worrying symptom emerges. Medications

Acute Migraine Treatment

 

RX: Sumatriptan 50 mg tablets

Sig: One tablet (50mg) during onset of migraine headache. If symptoms persist after 2 hours, take one more tablet (Chu et al., 2024)

Maximum dosage: 200 mg within 24 hours

Refills: Twice

RX: Naproxen 500 mg tablets

Sig: One tablet twice daily (orally), after meals

Maximum: 1000 mg/day unless otherwise as recommended by physician

Dispense: 20 tablets

Refills: 1

Preventive therapy is necessary for the patient since she gets migraines 2-3 times a week. Therefore, she should have Propranolol tablets (Soriano, 2026)

Rx: Propranolol 40 mg tablets

Sig: One tablet twice daily (orally)

Dispense: 60 tablets

 

It is essential to monitor the patient’s

• Heart rate
• Blood pressure
• Fatigue levels and
• Contraindications that include possible bradycardia and development of asthma

Patient Education

The patient should understand that migraine is a chronic neurological condition and aura symptoms are temporary. These symptoms go away before the headache starts.

The patient should take sumatriptan immediately the migraine symptoms begin, ideally early when the attack begins. She needs to avoid acute migraine medications for over ten days in a month to lower the risk of over-use of medications (Chen et al., 2025). The patient should also understand the adverse effects of the prescribed medications, and seek attentions if they persist and become severe.

She should seek urgent medical attention for:

• Sudden and severe headache
• Worsening neurological deficits
• Increased fever with neck stiffness
• Possible seizures
• Confusion and altered mental status

Lifestyle changes or modifications are essential for the patient to lower risks and triggers of migraine with aura. Consequently, the patient should:

• Get enough sleep; 7-9 hours every night
• Establish and maintain regular sleep and meal times or patterns
• Ensure sufficiently hydrated
• Have regular exercise at least 150 minutes a week of moderate physical activity
• Practice stress reduction interventions like meditation and mindfulness, yoga
• Reduce caffeine to less than 2 cups a day and avoid abrupt withdrawal
• She should avoid any possible migraine trigger (Chen et al., 2025)
• She needs to record and document aspects like
• Severity of the headaches
• Potential triggers of the headaches
• Symptoms of aura
• Medications she takes and
• Treatment response

 

Referrals / Consults

The patient does not require any referrals in the early or current stage of the condition. However, if the following occur, referral would be appropriate:

• Symptoms become atypical
• Frequency and severity of headache increase
• Failure of the first-line therapy
• Development of chronic migraines for instance over 15 headache incidences a month
• Persistent neurological symptoms
• Need for advanced preventive interventions
• Referral for ophthalmology may be appropriate if visual symptoms remain persistent

 

Follow-Up

Best practices based on evidence recommend appropriate follow-up to evaluate certain aspects between 4^th and 6^th focusing on the following:

• Frequency and severity of the headache
• Response to acute and preventive therapy
• Adherence to medications
• Presence of adverse effects (Shaker et al., 2022)
• Review or evaluation of headache diary
• The preventive therapy can be changed if headaches continue to be frequent after an appropriate trial time of about 6-8 weeks based on the therapeutic dosage

Conclusion

The diagnosis is consistent with migraine with aura and no evidence of a secondary headache condition. The management of the diagnosis confirms the clinical manifestation of the disorder, leading to integration of evidence-based acute treatment using sumatriptan, and starting preventive therapy based on the frequency of the attacks. Further, it entails determining the triggers, offering patient education on aspects such as lifestyle changes and medication utilization as well as reevaluating clinical response within 4-6 weeks. The approach adheres to the current evidence-based recommendations by the American Headache Society (AHS) and the American Academy of Neurology (AAN) to manage episodic migraine as a neurological condition that affects a significant number of young women.

References

Chen, Q., Zhang, J., Cao, B., Hu, Y., Kong, Y., Li, B., & Liu, L. (2025). Prediction

 

models for treatment response in migraine: a systematic review and meta-

 

analysis. Journal of Headache & Pain, 26(1), 1–13.

 

https://6o3071zy3-mp02-y-https-doi-org.prx-

 

Chu, K., Kelly, A. M., Kuan, W. S., Kinnear, F. B., Keijzers, G., Horner, D., Laribi, S.,

 

Cardozo, A., Karamercan, M. A., Klim, S., Wijeratne, T., Kamona, S., Graham, C.

 

A., Body, R., & Roberts, T. (2024). HEAD and HEAD-Colombia study groups.

 

Predictive performance of the common red flags in emergency department

 

headache patients: A HEAD and HEAD-Colombia study. Emergency Medicine

 

Journal, 41(6), 368–375. https://doi.org/10.1136/emermed-2023-213461

 

Hervik, J. B., Foss, E. B., & Stub, T. (2023). Living with chronic headaches: A qualitative

 

study from an outpatient pain clinic in Norway. Explore, 19(5), 702-709.

 

https://doi.org/10.1016/j.explore.2023.01.004

 

Haghdoost, F., & Togha, M. (2022). Migraine management: Non-pharmacological points

 

for patients and health care professionals. Open medicine (Warsaw, Poland),

 

17(1), 1869–1882. https://doi.org/10.1515/med-2022-0598

 

Ratti, E., Morrison, M., & Jakab, I. (2025). Ethical and social considerations of applying

artificial intelligence in healthcare—a two-pronged scoping review. BMC Medical Ethics, 26(1), 68. https://doi.org/10.1186/s12910-025-01198-1

 

Shaker, L., Ripper, J., & Murano, T. (2022). 55-year-old woman with headache,

 

vomiting, and visual disturbance. Clinical Practice and Cases in Emergency

 

Medicine, 4(2), 116. doi: 10.5811/cpcem.2019.12.45546

 

Soriano, R. P. (2026). Bates’ guide to physical examination and history taking (14th

ed.). Wolters Kluwer Health.

 

SECTION 5: Reflection on AI Use

Artificial intelligence (AI) and its associated is becoming a core part of doing research for students, including nursing students as it helps gather evidence on various aspects of care delivery. In this assignment, I used Chat GPT as a tool to help do the paper based on the case presented by the patient. The tool is accurate as it offers appropriate information and gives a detailed approach to the case. The tool is useful as it shows best practices and recommendations for the diagnoses, especially differential diagnoses for the symptoms presented by the patient. However, the tool requires one to conform the information it gives to ascertain accuracy and application in practical settings. The information was fundamental in developing the management plan. Additionally, verifying the information through credible sources was essential since AI can make serious mistakes, especially if it does not have the information when it lacks in the system. Ethical use of AI is essential to ensure that one gets verified information instead of providing false or misinformation when developing patient management plan for the diagnosis (Ratti et al., 2025). The implication is that the assignment offered an opportunity to use AI tools such as Chat GPT to get evidence and information about the presented case study.

 

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ASSIGNMENT: USE OF AI IN EVIDENCE-BASED PLAN MANAGEMENT

This assignment integrates clinical reasoning with the ethical use of artificial intelligence (AI) to develop an evidence-based management plan for a neurological or psychiatric condition. You will use AI tools to assist in generating differential diagnoses, identifying a final diagnosis, and creating a comprehensive management plan—then verify all information using current clinical practice guidelines and your own clinical judgment.

Through this activity, you will strengthen your ability to apply advanced documentation, diagnostic reasoning, and ethical decision making while evaluating the accuracy and limitations of AI in clinical care.

Level 4: AI as a Learning Partner

• AI use is required and may be used to help generate, analyze, or refine responses
• Often paired with reflective or practice?focused assignments

Required Resources

NOTE: Utilize this text as a clinical reference to aid your analysis for the relevant areas noted. Also utilize study questions to develop your understanding of the concepts and topics presented throughout this course.

• Soriano, R. P. (2026). Bates’ guide to physical examination and history taking (14th ed.). Wolters Kluwer Health.
  • Chapter 11, “Cognition, Behavior, and Mental Status”
  • Chapter 27, “Nervous System”
• Chu, K., Kelly, A. M., Kuan, W. S., Kinnear, F. B., Keijzers, G., Horner, D., Laribi, S., Cardozo, A., Karamercan, M. A., Klim, S., Wijeratne, T., Kamona, S., Graham, C. A., Body, R., & Roberts, T. (2024). HEAD and HEAD-Colombia study groups. Predictive performance of the common red flags in emergency department headache patients: A HEAD and HEAD-Colombia studyLinks to an external site.. Emergency Medicine Journal, 41(6), 368–375. https://doi.org/10.1136/emermed-2023-213461
• Khosravi, M., Zare, Z., Mojtabaeian, S. M., & Izadi, R. (2024). Artificial intelligence and decision making in healthcare: A thematic analysis of a systematic review of reviewsLinks to an external site.. Health Services Research and Managerial Epidemiology, 11, 23333928241234863. https://doi.org/10.1177/23333928241234863
• Ratti, E., Morrison, M., & Jakab, I. (2025). Ethical and social considerations of applying artificial intelligence in healthcare—a two-pronged scoping reviewLinks to an external site.. BMC Medical Ethics, 26(1), 68. https://doi.org/10.1186/s12910-025-01198-1
• Document: Week 9 Assignment Template (Word) SEE ATTACHMENT

 

To prepare:

• Review all Week 9 Learning Resources, including materials on ethical AI use and evidence-based practice guidelines for neurological and psychiatric conditions.
• Download and review the Assignment TemplateDownload Download and review the Assignment Template.
• Your instructor will assign a neurological or psychiatric case study scenario found in course Announcements.
• Review current clinical practice guidelines (e.g., APA, AAN, AAFP, CDC, or USPSTF) relevant to your assigned condition.

The Assignment (Template) 

Analyze your assigned patient scenario (posted in Week 9 Announcements) and use an AI tool (such as ChatGPT, GROK, etc.) to assist in creating the following:

• Differential Diagnoses (3–5): List and provide a rationale for each diagnosis, using subjective, objective, and pertinent history findings to rule out each differential diagnosis.
• Final Diagnosis: Identify the final diagnosis with a rationale supported by subjective, objective, and pertinent history findings that rule in the diagnosis according to evidence-based guidelines.
• Final Problem Statement: Write a problem statement with positive, negative, subjective and objective findings and pertinent history.
• Evidence-Based Management Plan: Include diagnostics, medications, referrals/consults, patient education, and follow-up, verified against evidence-based clinical guidelines. Use a minimum of 3–5 peer-reviewed, scholarly sources published within the last 5 years. Cite all sources used with in-text citations and a corresponding list of references.
  • Complete and appropriate first-line medication orders (dose, route, frequency, duration, quantity, refills); thorough patient education including diagnosis explanation, medication teaching, lifestyle guidance, and red-flag symptoms; appropriate referrals with clear justification; and specific follow-up instructions including timeframe, purpose, and ED/urgent care precautions.)
• Reflection on AI US: Write a brief paragraph discussing the accuracy, usefulness, and limitations of AI in developing your management plan.
• Use of AI: Ensure all AI-generated recommendations are verified and adjusted based on clinical judgment and guideline validation.
• Appendix: Include copies of prompts entered and outputs generated.