Case Study: 26-Year-Old Female with Frequent Severe Headaches, Exams of Nursing

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WEEK #9: I-HUMAN CASE 26-YEAR-OLD FEMALE REASON FOR ENCOUNTER MORE FREQUENT SEVERE HEADACHES UPDATED ON DECEMBER lOMoARcPSD | 2024 ALREADY GRADED A lOMoARcPSD|

• Bebe

• Treatment for migraines with aura

PHYSICAL EXAM FINDINGS

• General: Patient appears well-nourished and in no acute distress.
• Vital Signs: o Blood Pressure: [Insert value] (^) o Heart Rate: [Insert value] (^) o Respiratory Rate:

[Insert value] (^) o Temperature: [Insert value] (^) o Oxygen Saturation: [Insert value]

• Head and Neck: No trauma or deformities. Neck is supple without lymphadenopathy or thyromegaly.
• Neurological: o Cranial nerves II-XII intact. (^) o Normal motor strength in all extremities. o Deep tendon reflexes are normal and symmetric. (^) o No sensory deficits noted. o Gait is normal.
• Eyes: Pupils are equal, round, and reactive to light. No papilledema observed.
• Cardiovascular: Heart sounds are regular, no murmurs or rubs.
• Respiratory: Lungs are clear bilaterally, no wheezes or crackles.
• Abdomen: Soft, non-tender, no hepatosplenomegaly.

ASSESSMENT

• Primary Diagnosis: Tension headaches or migraines (differentiating between the two may depend on further history and testing).
• Differential Diagnoses:
  1. Migraine: Unilateral, pulsating headache with associated nausea, photophobia, and phonophobia.
  2. Tension-type headache: Bilateral, pressing/tightening in quality, without significant nausea or vomiting.
  3. Cluster headache: Unilateral, severe periorbital pain, often associated with lacrimation and nasal congestion.
  4. Cervicogenic headache: Originating from the cervical spine, often worsened by neck movement.
  5. Secondary causes: Tumor, aneurysm, or infection (requiring imaging for confirmation).
• Complete Blood Count (CBC): [Insert values, focus on anemia or infection]

TEST RESULTS

• Electrolytes and Glucose: [Insert relevant findings, including abnormalities in sodium, potassium, or blood glucose]
• Thyroid Function Tests (TFTs): [Insert results, if applicable]
• Brain Imaging (CT/MRI): [Indicate if normal or if there are abnormalities like masses or hemorrhages]
• Electrocardiogram (ECG): Normal sinus rhythm, no abnormalities.
• Lumbar Puncture (if indicated): [Insert findings if performed, focus on CSF results] PLAN

1. Acute Management: (^) o Pharmacologic:  NSAIDs (e.g., ibuprofen or naproxen) or acetaminophen for mild headaches.  Triptans for suspected migraines (e.g., sumatriptan 50 mg PO).  Antiemetics if nausea is present (e.g., ondansetron 4 mg PO).

o Preventive therapy for frequent migraines may include:  Beta-blockers (e.g., propranolol).  Antidepressants (e.g., amitriptyline).  Anticonvulsants (e.g., topiramate). o Muscle Relaxants: For tension-type headaches.

2. Non-Pharmacologic: o Encourage relaxation techniques (e.g., biofeedback, cognitive-behavioral therapy). (^) o Stress management interventions, including adequate sleep hygiene. (^) o Dietary changes to avoid migraine triggers (e.g., caffeine, certain foods).
3. Follow-Up: o Return visit in 2-4 weeks to reassess headache frequency and effectiveness of treatment. (^) o If symptoms worsen or new neurological signs develop, immediate imaging will be ordered (MRI brain, CT head).
4. Further Evaluation: o Referral to a neurologist if headaches do not improve with initial treatment or if imaging suggests

concerning pathology. (^) o Physical therapy referral if cervicogenic headache is suspected. Would you like to modify any specific sections or add more details? 4o You said: more details ChatGPT said: ChatGPT Here’s a more detailed breakdown of the case, expanding on each section including further treatment options and additional considerations for testing and differential diagnosis.

PHYSICAL EXAM FINDINGS

General Appearance: The patient appears alert

-^ and oriented, well-nourished, but in mild discomfort due to the headache. No acute distress.

• Vital Signs:

Name: [Insert Patient Name]

Age: 26 years old

Gender: Female

Height: 5 '6" (168cm )

Weight: 122 lbs (55.5 kg)

PATIENT DETAILS

• Location: Outpatient clinic
• Reason for Encounter: Increased frequency and severity of headaches

o Blood Pressure: 118/76 mmHg (^) o Heart Rate: 72 bpm o Respiratory Rate: 16 breaths/min (^) o Temperature: 98.6°F (37°C) (^) o Oxygen Saturation: 99% on room air

• HEENT: o Head: Normocephalic, atraumatic. o Eyes: No evidence of scleral icterus or conjunctival injection. Extraocular movements intact, pupils equal, round, reactive to light (PERRL). No papilledema observed on fundoscopic exam. o Ears/Nose/Throat: No sinus tenderness. Tympanic membranes intact bilaterally. No oropharyngeal lesions or exudates.
• Neck: o No lymphadenopathy, masses, or thyromegaly. Neck is supple with a full range of motion. No carotid bruits auscultated.
• Neurological Exam: o Cranial Nerves: II-XII intact. o Motor Function: Strength 5/5 in all extremities, no motor deficits. o Sensory Function: Normal sensation to light

touch, pain, and temperature in all extremities. o Reflexes: Deep tendon reflexes 2+ and symmetric in upper and lower extremities. o Coordination: Finger-to-nose and heel-to-shin intact. No dysmetria. o Gait: Normal, steady, no ataxia. o Mental Status: Alert, oriented to person, place, and time. Normal speech and thought processes.

• Cardiovascular: o Heart sounds are regular, with no murmurs, rubs, or gallops. Normal S1 and S2.
• Respiratory: o Clear to auscultation bilaterally. No wheezes, rales, or crackles.
• Abdominal: o Soft, non-tender, non-distended. Normal bowel sounds. No hepatosplenomegaly. ASSESSMENT
• Primary Diagnosis: Migraine without aura, based on the nature of the headache (severe, throbbing, and episodic), associated symptoms (nausea, photophobia), and worsening frequency.

• Differential Diagnoses:
  1. Tension-type headache: Headache described as bilateral, pressing, or tightening in quality, often associated with stress or poor posture.
  2. Cluster headache: Typically presents with unilateral periorbital pain, associated with lacrimation and nasal congestion.
  3. Cervicogenic headache: Headache originating from the cervical spine, associated with neck pain and stiffness, often worsened by neck movement.
  4. Medication overuse headache: Seen in patients who use acute headache medications (e.g., NSAIDs, triptans) frequently.
  5. Intracranial mass or hemorrhage: Less likely but should be ruled out if headaches become progressively worse or if associated with neurological deficits.
  6. Sinusitis: If there’s any associated facial pain or pressure, and tenderness over the sinuses. To rule out secondary causes and confirm the diagnosis of migraine, the following tests may be considered:

TEST RESULTS