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Comprehensive iHuman Case Study: 26-Year-Old Female Patient with Severe Frequent Headache, Exams of Nursing

Comprehensive iHuman Case Study: 26-Year-Old Female Patient with Severe Frequent Headaches (Class 6512) - Week #9 Comprehensive iHuman Case Study: 26-Year-Old Female Patient with Severe Frequent Headaches (Class 6512) - Week #9 Comprehensive iHuman Case Study: 26-Year-Old Female Patient with Severe Frequent Headaches (Class 6512) - Week #9 Comprehensive iHuman Case Study: 26-Year-Old Female Patient with Severe Frequent Headaches (Class 6512) - Week #9 Comprehensive iHuman Case Study: 26-Year-Old Female Patient with Severe Frequent Headaches (Class 6512) - Week #9

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Download Comprehensive iHuman Case Study: 26-Year-Old Female Patient with Severe Frequent Headache and more Exams Nursing in PDF only on Docsity! Comprehensive iHuman Case Study: 26-Year-Old Female Patient with Severe Frequent Headaches (Class 6512) - Week #9 Patient Information: Name: Kathleen Parks Age: 26 Gender: Female Occupation: Graphic Designer Reason for Encounter: Kathleen presents with a notable increase in the frequency and severity of her headaches over the past three months Chief Complaint: Kathleen describes her headaches as frequent, severe, and debilitating, with an increasing impact on her daily life and work performance. History of Present Illness: Onset: Symptoms began approximately three months ago. Frequency: Headaches occur nearly every day. Duration: Each headache lasts several hours, with some extending into the next day. Intensity: Pain is described as throbbing and severe, rated 8/10 on the pain scale. Location: Primarily affects the frontal and temporal regions Associated Symptoms: Nausea, photophobia, and occasional aura (visual disturbances such as flashes of light or blind spots) Aggravating Factors: Stress, long periods of computer use, and lack of sleep. Relieving Factors: Limited relief with over-the-counter medications such as ibuprofen or acetaminophen. Rest and dark, quiet environments provide some temporary relief e Kathleen reports that her headaches have become more frequent, occurring almost daily. The pain is described as throbbing and primarily located in the frontal and temporal regions. She notes that the headaches are often accompanied by nausea and photophobia (sensitivity to light). Over-the-counter analgesics provide limited relief History of Present Illness (HPI) Questions and Answers 41. When did your headaches start? Answer: Kathleen reports that her headaches began approximately three months ago. 2. Can you describe the headaches? o Answer: Kathleen describes her headaches as throbbing and severe. The pain is primarily located in the frontal and temporal regions of her head 3. How often do you experience these headaches? o Answer: Kathleen experiences headaches nearly every day. 4. How long do the headaches last? o Persistent dizziness occurring daily. o Sensation of spinning (vertigo) and unsteadiness, especially when standing.  Associated Symptoms: o Tinnitus (ringing in the ears) o Mild headaches o Occasional blurred vision  Treatment History: o Over-the-counter medications have not alleviated symptoms. o Dizziness significantly interferes with daily activities, including work and exercise. History and Physical Questions (HPQ) 1. When did your dizziness begin? o My dizziness started about a month ago. 2. Can you describe the sensation you experience? o It feels like the room is spinning, and I often feel unsteady, especially when I try to stand up. 3. How frequently do you experience these symptoms? o I experience dizziness almost every day, particularly in the mornings. 4. How long does each episode of dizziness last? o Each episode can last anywhere from a few minutes to several hours. 5. On a scale of 1 to 10, how severe is the dizziness when it occurs? o The dizziness feels like a 7 out of 10; it’s quite uncomfortable. 6. Are there any other symptoms associated with the dizziness? o Yes, I have a constant ringing in my ears (tinnitus) and sometimes experience mild headaches and blurred vision. 7. Have you noticed any specific triggers for your dizziness? o Rapid head movements, standing up too quickly, and being in crowded places seem to make it worse. 8. What measures have you taken to alleviate the dizziness? o I’ve tried using over-the-counter motion sickness tablets, but they haven’t helped much. Resting sometimes helps relieve the symptoms. 9. Have there been any recent changes in your routine or lifestyle that could relate to the dizziness? o Yes, I’ve been more stressed than usual with work, and I’ve also had some sleepless nights recently. 10. Do you have a history of similar symptoms, or is this a new occurrence? o This is a new occurrence for me; I’ve never experienced dizziness like this before. 11. How has this dizziness affected your daily life and work? o It has significantly impacted my ability to focus at work and has made it difficult to exercise or participate in social activities. 12. Have you tried any specific treatments or interventions to manage the dizziness, and what were the results? o I’ve only used over-the-counter medications with minimal success; I haven’t consulted a doctor yet for further options. 13. Is there a family history of similar symptoms or medical conditions? o My grandmother had episodes of dizziness, but there’s no significant family history of chronic conditions related to this. 14. Have you had any significant life changes that could be contributing to these symptoms? o Yes, I recently started a new job that has been quite stressful, which might be affecting my overall well-being. History of Present Illness (HPI)  Onset: Headaches started approximately three months ago.  Frequency: Occurring nearly every day.  Duration: Each headache lasts several hours, with some extending into the next day.  Intensity: Rated 8/10 on the pain scale, described as throbbing.  Location: Primarily in the frontal and temporal regions.  Associated Symptoms: o Nausea. o Photophobia (sensitivity to light). o Occasional aura (visual disturbances).  Aggravating Factors: o Stress. o Extended computer use. o Lack of sleep.  Relieving Factors: o Limited relief from over-the-counter medications (ibuprofen and acetaminophen). o Rest in a dark, quiet environment helps alleviate symptoms. Past Medical History (PMH)  No significant chronic illnesses.  Occasional seasonal allergies controlled with antihistamines.  No prior history of migraines or chronic headaches. Family History (FH)  Mother: Suffers from migraines.  Father: Has hypertension but no neurological conditions. Social History (SH)  Non-smoker, occasional social drinking.  Works as a graphic designer, leading to long hours in front of a computer screen.  Lives alone, exercises regularly, but reports stress from work deadlines.  Experiences irregular sleep patterns (averaging 5-6 hours nightly), worsening headaches. Review of Systems (ROS)  General: Reports fatigue due to sleep disruption.  HEENT: Frequent headaches, nausea, and photophobia; no visual changes.  Cardiovascular/Respiratory: No chest pain or difficulty breathing.  Gastrointestinal: Occasional nausea linked to headaches.  Neurological: No seizures, dizziness, or weakness; recurrent headaches. Differential Diagnosis  Chronic Migraine (Most Likely) o Rationale:  Headaches occur more than 15 days per month. o Coordination: Normal. o Sensory Examination: Normal.  HEENT (Head, Eyes, Ears, Nose, Throat): o No abnormalities observed in eyes, ears, nose, or throat. o No signs of visual changes or abnormalities noted.  Cardiovascular: o Normal heart sounds, no murmurs.  Respiratory: o Clear lung sounds, no wheezing or abnormal lung sounds.  Abdomen: o Soft, non-tender, no organomegaly. Treatment Plan for Kathleen Parks 1. Pharmacologic Management Preventive Therapy:  Topiramate: Continue at 100 mg daily. Effective for reducing migraine frequency, with mild side effects.  Propranolol: Continue at 40 mg daily. Beneficial for migraine prevention, especially in patients with anxiety. Acute Management:  Sumatriptan: Continue as needed for acute migraine relief, taken at headache onset. Effective in aborting migraine attacks. 2. Non-Pharmacologic Management Lifestyle Modifications:  Sleep Hygiene: Maintain a consistent sleep schedule of 7-9 hours per night; improve sleep environment (dark, quiet).  Hydration: Advise regular fluid intake to prevent dehydration-related headaches.  Stress Management: Encourage techniques such as: o Yoga or Pilates: For physical relaxation. o Mindfulness or Meditation: To manage stress. Cognitive Behavioral Therapy (CBT):  Consider referral to CBT for stress and anxiety management, which can help reduce migraine frequency. Headache Diary:  Instruct Kathleen to maintain a detailed diary documenting: o Dates and times of headaches o Duration and severity (1-10 scale) o Associated symptoms (e.g., nausea, photophobia) o Potential triggers (e.g., stress, screen time) 3. Follow-Up and Monitoring Next Appointment:  Schedule for 6-8 weeks to assess treatment effectiveness, monitor side effects, and adjust medications as necessary. Long-Term Plan:  Evaluate the need for ongoing preventive treatment based on headache frequency and severity.  Discuss potential tapering of medications if migraines become well-controlled.  Monitor for any side effects from preventive medications, adjusting treatment as needed. Follow-Up Visit (12 weeks after second follow-up) Subjective:  Kathleen reports improvement in headaches: frequency reduced to once weekly, with some weeks headache-free. Acute headaches are less severe and responsive to sumatriptan. She feels more in control and has resumed hobbies. Medication Adherence:  Continues taking topiramate and propranolol as prescribed. Sumatriptan used twice with good results. Side Effects:  Mild tingling in fingers/toes persists but is manageable and not bothersome. Lifestyle Modifications:  Kathleen consistently practices regular exercise, structured sleep, and mindfulness techniques. Objective:  Vital Signs: BP 110/68 mmHg, HR 66 bpm, Temp 98.1°F, RR 16 breaths/min.  Neurological exam: unchanged with no new findings. Assessment:  Chronic migraines show continued improvement; frequency and severity reduced. Mild tingling remains manageable. Management Plan  Continue Current Medications: o Topiramate: Maintain at 100 mg daily. o Propranolol: Continue at 40 mg daily. o Sumatriptan: Use as needed for acute attacks.  Monitor and Manage Side Effects: o Continue monitoring tingling sensation; adjust treatment if problematic.  Reinforce Lifestyle Modifications: o Encourage maintenance of healthy lifestyle practices.  Potential Tapering of Medication: o If headaches remain controlled, discuss gradual tapering of preventive medications at the next visit.  Follow-Up: o Schedule next visit in 3 months or sooner if symptoms change. Summary: Kathleen has shown continued improvement in her chronic migraine management, allowing for a more active lifestyle. Treatment will continue with ongoing monitoring and potential discussions for tapering medications based on future evaluations. Present Illness (PI): Kathleen Parks, a 26-year-old female, presents with persistent dizziness and lightheadedness that began approximately one month ago. The dizziness occurs almost daily and is characterized by a spinning sensation (vertigo) and unsteadiness, especially upon standing. Associated symptoms include tinnitus, mild headaches, and occasional blurred vision. Over-the-counter medications have provided minimal relief, and the dizziness has significantly impacted her daily activities, including work and exercise. Past Medical History (PMH):  No significant medical history reported.  No history of migraines or other neurological disorders.  No previous episodes of dizziness or vertigo noted. Family History (FH):  Mother has a history of migraines.  Grandmother experienced episodes of dizziness.  No known family history of significant neurological or vestibular disorders. Social History (SH):  Non-smoker.  Occasional alcohol use.  Works full-time in an office environment, which has become increasingly stressful recently.  No regular exercise routine; reports a recent decline in physical activity due to dizziness. Review of Systems (ROS):  General: Reports fatigue and increased stress levels.  Neurological: Dizziness, spinning sensation, occasional blurred vision, no syncope or loss of consciousness.  Ophthalmic: Blurred vision episodes; no other vision changes reported.  Otolaryngologic: Tinnitus present, no hearing loss reported.  Musculoskeletal: No joint or muscle pain noted. Differential Diagnosis: 1. Benign Paroxysmal Positional Vertigo (BPPV): o Characterized by episodes of vertigo triggered by changes in head position. 2. Vestibular Neuritis: o Viral inflammation of the vestibular nerve leading to acute onset of vertigo and imbalance. 3. Meniere's Disease: o Characterized by episodes of vertigo, tinnitus, hearing loss, and a feeling of fullness in the ear. 4. Migrainous Vertigo: o Episodes of vertigo associated with migraine headaches, which Kathleen reports experiencing. 5. Orthostatic Hypotension: o Dizziness upon standing due to blood pressure changes; this can be exacerbated by dehydration or prolonged sitting. 6. Anxiety or Stress-related Dizziness: o Dizziness can be a manifestation of anxiety or stress, particularly with her high- stress job. Management Plan: 1. Initial Assessment and Tests: o Physical Examination: Conduct a thorough neurological exam and vestibular assessment. o Audiometry: To evaluate hearing function and assess for any hearing loss associated with tinnitus. o Vestibular Function Tests: Consider ENG (electronystagmography) or VNG (videonystagmography) to assess vestibular function. o Blood Tests: CBC, metabolic panel, and thyroid function tests to rule out other causes of dizziness. 2. Lifestyle Modifications: o Stress Management: Recommend stress-reduction techniques such as yoga, meditation, or counseling to manage high stress levels. o Sleep Hygiene: Encourage regular sleep patterns and adequate rest to combat fatigue and dizziness. 3. Pharmacological Treatment: o Antihistamines: Consider prescribing meclizine or dimenhydrinate for symptomatic relief of vertigo. o Migraine Prophylaxis: If migraines are suspected, consider medications such as topiramate or propranolol, depending on her overall health and tolerance. o Antidepressants or Anxiolytics: If stress or anxiety is identified as a significant factor, discuss the potential for short-term use of these medications. 4. Follow-Up Care: o Schedule a follow-up appointment to assess symptom progression and response to initial management. o Refer to a neurologist or otolaryngologist if symptoms persist or worsen, especially for vestibular testing or further evaluation. 5. Education: o Provide education about her symptoms and potential causes to alleviate anxiety. o Inform about the importance of hydration and regular meals to help manage symptoms.