Comprehensive I Human Case Week #9 26Years Old Female Reason For Encounter: Frequent Sever, Exams of Nursing

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Comprehensive I Human Case Week #9 26 Years Old Female Reason For

Encounter: Frequent Severe Headache

Location; Outpatient Clinic Case Study (Class 6512)

NEWEST I HUMAN CASE VERSION UPDATED ON OCTOMBER 2024

SOURCED FROM CHAMBERLAIN UNIVERSITY MEDICAL CARE EXPERTS

PMHx child/adult illness/hospitalizations/immunizations No medical issues No prior surgery No OB/GYN issues - menstruation is regular and no issues G0P Wears helmet when biking Plays sports - soccer Nutrition: “regular American diet”; tries to minimize junk food Immunizations: Up to Date except HPV, first dose of meningococcal at age 12, Tdap at age 12 SurgHx None

FamHx Grandparents (if known)/Parents/siblings/children SHx Father: Unknown Mother: Longstanding headaches Siblings: None Spouse/offspring: N/A Tobacco/vaping/ETOH/illicit drug use/occupational/environmental/relationships Lives with mother in single parent home Housing: single-occupancy apartment Student: gets straight "As" Substance use: no smoking, no alcohol, no recreational drugs Denies being sexually active

Reproductive Hx Female: Menarche unknown dates Last period 2 weeks ago Not sexually active Allergies (Food, Drug, Environmental, etc) NKA List of Current Medications/supplements (prescription, OTC, complementary alternative therapies) Acetaminophen or Advil PRN for headaches Excedrin as needed Benadryl PRN for sleep

Review of Systems: (ROS) Use this column to document the ROS below. General: Denies any problems with fatigue, difficulty sleeping unintentional weight loss or gain, and night sweats Skin/Breasts: Denies any problems with itchy dry scalp, skin changes, moles, thinning hair, or brittle nails From the ROS: list/highlight the current symptoms/complaints to generate a list of pertinent “reported or denied” symptoms below:

Denies any breast discharge, lumps, scaly nipples, pain swelling, or redness Eyes: States "visual distortions, blurry wiggly stuff at the edges of eyes, like a "thin veil" ENT: Denies any drainage, swelling, redness Pulmonary: Denies SOB at night or at rest or when lying down, denies cough, wheezing or difficulty catching breath, chronic cough or sputum production CV: Denies palpitations, pain or discomfort, heavy feeling or sensation of a “pounding heart GI: Denies constipation, or heartburn. States normal bowel movements, states nausea, and vomited once with headache GU: Denies pain, burning, blood in urine, denies difficulty starting or stopping urinating, dribbling, incontinence, urgency during night or day, or any changes in the frequency of urination Eyes: States "visual distortions, blurry wiggly stuff at the edges of eyes, like a "thin veil" GI: Denies constipation, or heartburn. States normal bowel movements, states nausea, and vomited once with headache

Denies muscle weakness, joint pain, stiffness, redness or swelling Heme: Denies bruising, bleeding gums, nose bleeds, abnormal bleeding, or history of anemia Endocrine: Denies heat and cold intolerance, increased thirst, increased sweating, frequent urination, or changes in appetite Neuro: Denies dizziness, lightheadedness, fainting, room spinning, seizures, or weakness. States "more frequent, severe headaches start started 10-12 weeks ago, occurring every week", headache presents unilaterally on the left side of the head and is felt behind the eye, pain is rated 8 - 10/10. She says she has a sensitivity to light, loud noises, nausea, and vomiting. She states before the headache there are Neuro: Denies dizziness, lightheadedness, fainting, room spinning, seizures, or weakness. States "more frequent, severe headaches start started 10-12 weeks ago, occurring every week", headache presents unilaterally on the left side of the head and is felt behind the eye, pain is rated 8-10/10. She says she has a sensitivity to light, loud noises, nausea, and vomiting. She states before the headache there are visual distortions like "thin veils" at the edges. She also has a less severe secondary headache described as "band-like" involving the entire head, neck, and shoulders

visual distortions like "thin veils" at the edges. She also has a less severe secondary headache described as "band-like" involving the entire head, neck, and shoulders Psych: Denies anxiety, depression, loss of energy or changes in interests

Physical Exam: (PE) Use this column to document the PE below. Height: 5' 6" (168.0 cm) Weight: 122 lb (55.0 kg) (BMI 19.7) Temperature: 98.6 F (oral) Pulse: 74 bpm - regular Blood pressure: 118/68 mmHg - supine/sitting Blood pressure: 116/62 mmHg - upon standing Respiratory rate: 12 bpm SpO2: 99% on room air General: Thin, pleasant, cooperative female, alert and oriented x Skin/Breast: Warm, dry and intact, no redness, lesions, or bumps noted Breasts: Deferred Eyes: Lashes without crusting, eyelids without edema, erythema. Conjunctivae pink, no discharge. No orbital edema, redness, tenderness From the PE: list/highlight the presence or absence of objective findings to generate a list of pertinent “(+) or (-)” symptoms below: Pertinent (-) Eyes: Lashes without crusting, eyelids without edema, erythema. Conjunctivae pink, no discharge. No orbital edema, redness, tenderness Nose: Nares patent bilaterally, no nasal drainage or polyps, septum midline and intact, no edema or tenderness over frontal or maxillary sinuses, Sinuses non-tender to light percussion, no temporal artery tendernes Neck: No visible scars, deformities, or lesions, the trachea is midline and mobile, no cervical mass or regional lymphadenopathy, full cervical-spine ROM

Ears: Pinna and tragus without tenderness upon manipulation bilaterally. Canals are clear bilaterally, tympanic membrane pearly, translucent, and pinkish-gray in color with intact landmarks bilaterally Nose: Nares patent bilaterally, no nasal drainage or polyps, septum midline and intact, no edema or tenderness over frontal or maxillary sinuses, Sinuses non-tender to light percussion, no temporal artery tenderness Neuro: CN II-XII grossly intact, normal gait and posture, no involuntary movements noted patellar and brachial reflexes 2+ bilaterally, no facial asymmetry MSK: No tenderness, muscular resistance, rigidity, asymmetry, or deformity noted, ROM is equal bilaterally on upper and lower extremities

Neck: No visible scars, deformities, or lesions, the trachea is midline and mobile, no cervical mass or regional lymphadenopathy, full cervical-spine ROM Pulm: Respirations even and unlabored bilaterally, good chest wall expansion, lung sounds clear to auscultation bilaterally both anterior and posterior CV: Heart rate and rhythm normal, no significant change while standing, squatting and during Valsalva maneuver, no JVD. 2+ peripheral pulses x4 extremities, PMI in the 5th intercostal (ICS) at the midclavicular line (MCL) GI: Lean, non- distended, no scars noted, bowel sounds audible in all 4 quadrants, no hepatosplenomegaly, the spleen is non- palpable, no mass or herniation upon palpation, no abnormal pulses noted GU: Deferred Neuro: CN II-XII grossly intact, normal gait and posture, no involuntary movements noted patellar and brachial reflexes 2+ bilaterally, no facial asymmetry

MSK: No tenderness, muscular resistance, rigidity, asymmetry, or deformity noted, ROM is equal bilaterally on upper and lower extremities Lymph: No pathologically enlarged lymph nodes in the cervical, supraclavicular, axillary, or inguinal chains Heme: Deferred Psych: Cooperative, calm, friendly, answered all questions without hesitancy, no anxiety, distress or sadness noted

Lab/Radiology or other Diagnostic data reviewed today during virtual visit Problem Statement: 26 y/o female student presenting with more frequent, severe headaches start started 10-12 weeks ago, occurring every week. The headache presents unilaterally on the left side of the head and is felt behind the eye. Pain is rated 8-10/ and prevents the patient from doing any activities, and sometimes the pain last up to 15 hours. She says she has a sensitivity to light, loud noises, nausea, and vomiting. The intense throbbing

headache usually happens when there isn't enough sleep or after eating junk food and chocolate with friends. She states before the headache there are visual distortions like "thin veils" at theedges. theheadaches are relieved by a dark room and sleep, Tylenol or Advil. She also has a less severe secondary headache described as "band-like" involving theentire head, neck, and shoulders that is relieved by hot showers. She believes thesecondary headache is due to her position when studying. Her mom has a history of headaches. Upon examination there were no neurological changes noted, physical exam was unremarkable with no pertinent positives supporting her complaints.

List thedifferential diagnoses (Must not Miss/Leading/Alternate/Concluding – total of 3 *Include ICD 10 codes after each

**1. Migraines G43.909 LEADING (MUST NOT MISS, if one had to be selected)

2. Tension headache G44.209. ALTERNATE
3. Cluster headache G44.0. ALTERNATE**

Medication options: Acetaminophen PO 325 - 650 mg q4- 6 hours, NSAIDS or aspirin Plan No lab or diagnostic workup necessary at this time

Anti-nausea medication as needed such as Zofran, or Reglan Indomethacin PO 25 - 50 mg tid or qid (max 200 mg/day) Sumatriptan PO 25 mg Dihydroergotamine intranasal 1 spray (0.5mg) ineach nostril, repeat with additional spray 15 min if no relief (max 4 sprays per attack), wait 6 - 8 hours before treating another attack Propanolol 80 mg/day PO Verapamil 80 mg PO q 6- 8 hours

Lisinopril 5-40 mg day PO Valproic Acid 250 mg BID PO Plan and Education: Avoid chocolate, caffeine, alcohol, smoke which are migraine triggers Rest Ice applied to theback of theneck Hot showers Reduce stress by yoga, meditation, biofeedback, CBT, massage therapy

Massage Better sleep 8 hours a night Keep a headache diary to identify triggers Add exercise to thedaily routine Consult or Referral: Possible Neuro or Psych consult if pain is not relieved inthenext two weeks Follow up in8 weeks to evaluate medication efficacy, and evaluation of treatment plan

IHUMAN TOTAL CASE SCORES:

#1: 100

#2:

Based on patient’s age/risk factors, what preventive screening would be recommended at today’s or a future visit: Possible safety screening (bullying/IPV if applicable/home safety) Depression Screening Dietary counseling: trigger foods for migraines

Educate regarding healthy study habits, sleep habits, and healthy adolescent relationships