Frequent Severe Headaches in a 26-Year-Old Female, Exercises of Nursing

Download Frequent Severe Headaches in a 26-Year-Old Female and more Exercises Nursing in PDF only on Docsity! I Human Case Week #9 26 Year Old Female (Class 6512) Reason For Encounter Frequent Severe Headache location; Outpatient Clinic 2024 CASE STUDY PATIENT DETAILS • Name • Age: 26 years old • Height: 5'6" (168 cm) • Weight: 122 lbs. (55.5 kg) • Location: Outpatient clinic • Reason for Encounter: More frequent severe headaches | Relieving | (Often my vision in both eyes gets blurry at the edges before the Do you have any awareness or —_—| headache actually comes on. I can Timing/Treatments | warning symptoms that occur rriaperacald taka won | Bo eaiaths Degea? ly eyes are otherwise okay; its not bafore.tns nes like they're swollen or watering or anything. My vision is just blurred. But thats pretty much it Well, | haven't really been seen by a doctor for this. | use acetaminophen, but by the time | What treatments have you had for | take it, | can't keep it down because Timing/Treatments | your headache? | am so nauseated. Same with | ibuprofen. Acetaminophen and ibuprofen used to work, but now they really don’t help | Do your headaches occur when don't know. I don't have that much | @ = | Timing/Treatments | your caffeine intake changes? caffeine on a daily basis Oh, it's pretty unbearable. When my headaches start, it's 2 2 or a 3, and it becomes an 8 or even a 10 © | severty How severe (1-10 scale) is your | when it really gets going. | just cant | headache? o anything when | have one of my | Shown net meee | 15 hours, which means the entire day is shot. | [HPI | | PMH, FH, SH as Needed @ Asked X Not asked | Information Obtained Graded Approach Question Response Clinks Notes Can you tell me about any current | not much to tell. The usual @ PMH or past medical problems you have. | chidnood stuf Sometimes Benadryl for sieep e |My ‘Are you taking any over-the-counter | around finals time. | take or herbal medications? | acetaminophen or ibuprofen for | some of my headaches. @ ie Have you had any significant No | have not. Never been knocked | traumatic injuries or accidents? | out or anything like that. | think they had to be in order to . | start grad school. | also got my @ PMH Are your immunizations up to date? Naan caer ence cola | flu shot. @ (PMH | Doyou have any allergies? Not that | know of. | e |rw Ass you tna ary preserton Not ight now. SH Do you use any recreational drugs? | Maybe a little marijuana in the past, e If s0, what? | that's all. Nothing lately  PMH, FH, SH as Needed @ Asked X Not asked | | | Information Obtained Graded | Approach Question Response con | | | | Clinic Notes | | Can youtell me about any current | 1.4 | | ve | Net much to tell. The usual @ | PMH | er past mesical problems you have | orighood stuf. | | | Sometimes Benadryl for sleep | @ pun —_| Are you taking any over-the-counter | around finals time. | take | or herbal medications? | acetaminophen or ibuprofen for | head: | some we: | pear | Have you had any significant | No Ihave not. been knocked | | traumatic injuries or accidents? —_| out or anything like that. | | | [think they had to be in order to a start grad school. | also got my 2 © |PwH | Are yourimmunizations up to date? | ooet5 vaccine series and annual | | fu shot. @ PMH | Do you have any allergies? | Not that | know of, t T T a T T ] oe | rm Are eter any prescription | Not right now. eo osH | Do you use any recreational drugs? Maybe a little marijuana in the past, | | Ifo, what? | that’s all. Nothing lately | | Every now and then | have a glass | of red wine at the end of my [Deyousrneaacor to, wnat an, watesang a, Worn pare @ |sH | ord ia? and how many drinks Per | sometimes be stressful. | usually | Sa¥? | have about 2-3 glasses of red wine | | a week. They're maybe about 6 oz | | each. | | | [Vike chocbiate: Ws my ontyreal | | Do you drink caffeinated beverages | | : * e@ sH | | vice | guess. Maybe | overdo it 3 | | ‘or eat chocolate? | bit. | Review of Systems (ROS) Select the major body systems that have not been touched on during the interview process for the HPI. @ Asked X Not asked [Graded Question _Response [eeooetnt caer | ‘Do you expenence chest pain | | discomfort or pressure: @ | Painjpressureidizziness with exertion or | getting angry: palpitations; decreased | exercise tolerance; or blue/cold fingers and toes? Nope. Do you experience shoriness of breath, @ | wheezing. difficulty catching your breath. chronic cough, or sputum production? No.  @ Performed Correctly assess cranial nerves Assess cranial nerves in any patients with concerns of new or changing headache in order to evaluate for abnormalities. assess gait & stance Gait is part of a good neurological exam, which is essential for a patient with a concern of new or changing headache. auscultate abdomen © You performed the simulation correctly. auscultate carotid arteries © You performed the simulation correctly. auscultate heart Auscultate vital organs to ensure overall patient health. © You performed the simulation correctly. © You interpreted assessment correctly. blood pressure evaluate neck range of motion Evaluate cervical range of motion, especially flexion, for signs of meningeal irritation. A subtle limitation of cervical flexion may be clinically significant. inspect mouth/pharynx Headaches may be caused by upper respiratory and sinus issues, so evaluation of the pharyngeal mucosa is warranted. look in ears with otoscope Headaches may be caused by upper respiratory and sinus issues, so evaluation of the ear canals and TMs is warranted. look up nostrils Headaches may be caused by upper respiratory and sinus issues, so evaluation of the nasal mucosa is warranted. palpate neck Palpate the neck to look for muscle tension, adenopathy, or masses. perform ocular motor test © You performed the simulation correctly. pulse © You performed the simulation correctly. © You interpreted rate, rhythm, and strength correctly. respiration © You interpreted rate, rhythm, and effort correctly.  • Throat: trachea midline, no erythema, lesions, or deformed. No cervical par spinal muscles tenderness to pompano. No mass or regional lymphadenopathy. Thyroid moves with swallowing. • Respiratory: symmetrical expansion and anterior-posterior (AP) diameter is normal. No ad venous breath sounds or use of accessory muscles. No crepitus, tenderness, thrills, or rashes noted anterior or posterior of chest. Lung sounds clear to auscultate on. • Cardiac: No signs of JVD, heart palpation or murmurs. S1, S2 noted with regular rate and rhythm. • Abdomen: is at and symmetric with no scars, deformed, striate, or lesions. Bowel sounds are normoacve. No pain, tenderness, masses, or pulao’s. No guarding or rebound tenderness. No signs of hepatosplenomegaly. Liver span normal and spleen is no palpable. • Musculoskeletal: No swelling or deformed, no cyanosis, edema, or clubbing noted on extremes. No tenderness, muscular resistance or rigidity. Strength intact bilaterally in upper and lower extremes. • Neurological exam: • Balance test- Gait intact • Point to point test arms (anger to nose): anger to nose intact bilaterally without past-poisoning • Point-to-point test leg (heel down shin): heel to skin intact bilaterally without past-poisoning • Rapid alternating movement- anger: rapid alternating movement at hands intact bilaterally • Romberg’s and pronator dry s test- negative Romberg test, no pronators drinking • Rexes deep tendon – triceps, biceps, brachioradialis, knee/patella, ankle/Achilles –2 bilaterally • GU: normal. No masses or tenderness, normal pelvic exam • Rectal: no visible assures, induration or lesion • • 26 y/o female • 5’6’’ 122lbs • Reason for encounter: More frequent severe headaches • How can I help you today? – I have been having these bad headaches over the last few months. I do not have one now and have not had one in about a week, but I thought I would have it checked out anyway. • Do you have any other symptoms or concerns we should discuss? – just the symptoms that I always have had with these headaches, like nausea and vomiting • What symptom is the most distressing for you? – Well, I cannot work or study when I have one of my bad headaches, and I usually have to sleep the headache o. It is really messing with both my school and work responsibility is. In addition, I know this might sound crazy, but I am afraid it might be something serious, you know. Like a slowly growing brain tumor • Dose anything make your HA beer or worse? - It helps if I lie down in a dark room and try to sleep it. And definitely light and noise make the pain worse • Do any food seem to bring the HA on? – well, I seem to get them more when have been eating junk food • What does the pain in your head feel like? – throbbing • When more precisely is the pain in your head? – when I get a HA, its prey much on the le behind my eye • Does the pain in your head radiate somewhere else? Where? – no it doesn’t move anywhere else • How severe (1-10) is you are HA? – Oh it’s pre y unbearable. When my HA starts, it is a two or a three and it becomes an 8 or even 10 when it really get going. I just cannot do anything when I have one of my bad HA. They can last up to 15 hours which means the end re day is shot • No HA at night • Sleep helps • How quickly dose your HA come on? – Once it is triggered, it steadily increases. It is not like a whack of the head or anything. • Is there any pattern to when you are HA occurs? – They usually happen when I have not been sleeping enough. I have been having trouble with sleep and drinking more red wine recently given all my stress • Do you have any awareness or warning symptoms that occurs before the HA begins? – O end my vision in both eyes get blurry at the edges before the HA actually comes on. I can s all see; it is kind of like a thin veil. My eyes otherwise okay; it is not as they are swollen or watering or anything. My vision is just blurred. But that’s prey much it • What treatments have you had for you HA? - Well, I have not really been seen by a doctor for this. I use acetaminophen but by the me, I take it. I cannot keep it down because I am so nauseated. Same with ibuprofen. Acetaminophen and ibuprofen used to work but now they really don’t help • Can you tell me about any current or past medical problem you had? – Not much to tell. The usually childhood stud • Do you experience chest pain discomfort or pressure; pain with exert on or gang angry palpitation? • – no • Do you have any allergies? – no • Are your immunize on up to date? – I think they had to be in order to start graduate school. I also got my covid-19 vaccine series and annual u shot Your Problem Statement B.B. a 26-year-old female, presented at the office today with worsening headaches accompanied by nausea and vomiting. The patient has had a significant history of headaches for the past 10 years but has been having an increased frequency of headaches and worsening symptoms. Headaches are located behind the left eye, throbbing pain with an 8-10 in intensity and an aura of light and noise. A dark room relieves her symptoms and sleep. She has tried ibuprofen and acetaminophen with minimal relief. She has a family history of headaches (mother). Physical examination: normal neurological exam, cranial nerves intact with no neurological deficits. Case Problem Statement The patient is a 26-year-old female with a 10-year history of headaches who presents with incapacitating unilateral headaches increasing in frequency over the last few months. They now occur every 1-2 weeks, last up to 15 hours, and the patient endorses the consumption of chocolate, junk food, red wine, and compounding life stressors of graduate school and part-time work. She has premonitory blurred vision and associated nausea and vomiting with headaches, photophobia, and phonophobia. Her vital signs and physical exam are non-contributory. Your Differential Diagnoses Legend: @ Correct X Missed € Extraneous @ headache, migraine with aura @ headache, tension intracranial mass ( headache, cluster Feedback @ Correct 1. headache, migraine with aura 2. headache, tension X Missed You were missing 1 disease that was specified by the case author. 1. intracranial mass C Extraneous 1. headache, cluster Discussion 10-year history of stable-character headaches with recent increase in headache severity and frequency Premonitory bilateral visual blurring Nausea and vomiting with headache episodes Photophobia/phonophobia with headache episodes Headache localized behind left eye Incapacitation with headache episodes Migraine with aura Proceed Tension headache +/- + + Intracranial mass +/- Premonitory bilateral visual blurring + +e Nausea and vomiting with headache episodes + +h + Photophobia/phonophobia with headache episodes + +h Headache localized behind left eye ~ Incapacitation with headache episodes + Headaches associated with junk food, red wine, and life * “+: stressors Family history of headaches (mother) + Lack of trauma + + + Normal neurological examination +h * Migraine with aura: Given the character, pattern, and progression of the headaches described, this diagnosis should be considered. These findings, in concert with the patient's age, family history, and the overall chronicity of the headaches put migraine high on the differential diagnosis list. Tension headache: in the setting of headache with these key features, tension headache should be considered, especially given the patient's recent life stressors. Intracranial mass: Although masses are more rare in younger individuals, approximately 14.5% of all brain tumors occur in people aged 15-39. Trauma could induce a bleed or an AV malformation, which is genetic, could induce new or worsening symptoms. in the setting of increased severity and frequency of headaches, intracranial mass due to tumor or bleed are life- threatening causes of symptoms. They should be carefully considered on the differential list. Other diagnoses to consider Cluster headache: in the setting of headache with unilateral pain findings, consider cluster headaches. This is lower on the differential as they are generally not associated with triggers, such as foods and wine, and there were no specific unilateral ocular findings like tearing. + Meningitis, viral or bacterial: The classic triad of meningitis is fever, headache and nuchal rigidity, however not all patients will have all three symptoms. Almost all patients with meningitis complain of a headache. Meningitis, although unlikely given the chronicity of symptoms, should be considered given its serious potential sequelae. « Sinusitis: Given the patients’ unilateral symptoms, it is reasonable to consider sinusitis on the differential list. The lack of infectious symptoms in the history and lack of inflammation upon head and neck physical examination move this diagnosis lower on the differential list. « Intracranial hemorrhage: While worthy of consideration given its life-threatening nature, this diagnosis rarely occurs in patients who are in their 20s and without traumatic history. For this reason, intracranial hemorrhage is lower on the differential list. Plan Feedback Pharmacologic Care: « Give naproxen 500 mg once. + Give sumatriptan 50 mg once. Repeat once after 2 hours if needed. The maximum dose is 200 mg per 24 hours. + Metoclopramide 10 mg PO every 6-8 hours for nausea/vomiting, max 45mg daily. « Place neurology referral for further preventative care. Supportive Care: « Maintain appropriate daily hydration (3.7 L/15.5 cups for the average male and 2.7 L/11.5 cups for the average female). « Trigger avoidance: Avoid excessive red wine, chocolate, and junk food since these trigger migraines. « Pursue stress reduction through daily moderate-vigorous activity for 30 to 50 minutes 3 to 5 days per week or via other healthy means. Obtain adequate sleep (8 hours for adults) and avoid screen time 2 hours before bed. Reduce intake of caffeinated beverages. Patient Education: « Educated the patient on the diagnosis of migraine, the prognosis of disease with treatment, and treatment regimen, including indications, proper administration, side effects, and red flag symptoms for discontinuation. Educated the patient specifically on medication-overuse headaches. Recommended that the patient keep a headache diary to better understand headache patterns, triggers, and medication use. Discussed the importance of daily supportive care as planned above. Discussed the importance of follow-up to evaluate treatment efficacy. Discussed with the patient that prophylactic options are available, and if the current abortive treatment regimen is ineffective or is no longer desired, will discuss preventive treatment options and check on referral in follow-up. « Discussed red flag symptoms, such as thunderclap-quality headache, neck pain/stiffness in the setting of fever, and uncontrollable vomiting. Follow-Up: Follow up in the clinic in 6-8 weeks to establish treatment efficacy and adjust as needed. Follow up sooner for persistent migraines despite abortive treatment, change in headache character, or if migraines continue to increase in frequency or severity. « Go to ER for evaluation for thunderclap headache, worst headache of their life, severe increase in pain, uncontrollable vomiting, neck pain/stiffness associated with fever, or any other concerning symptoms.  • 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 photophobia. pathology. O Physical therapy referral if cariogenic headache is suspected. Would you like to modify any specific sections or add more details? 4o you said: more details Catgut said: Catgut Here is a more detailed breakdown of the case, expanding on each section including further treatment options and additional considerations for testing and differential diagnosis. PATIENT DETAILS • Name: [Insert Patient Name] • Age: 26 years old • Gender: Female • Height: 5'6" (168 cm) • Weight: 122 lbs. (55.5 kg) • Location: Outpatient clinic • Reason for Encounter: Increased frequency and severity of headaches 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: 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: Norm cephalic, atraumatic. o Eyes: No evidence of scleral icterus or conjunctival injection. Extraocular movement is intact; pupil is 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.  Trip tans: Samaritan 50-100 mg PO at the onset of headache, may repeat after 2 hours if necessary (max dose 200 mg/24 hours).  Anti-nausea medication: Ondansetron 4 mg PO or metoclopramide 10 mg PO for nausea associated with the headache. o Tension-type headaches:  Consider muscle relaxants (e.g., cyclobenzaprine 5-10 mg PO for tension or muscle spasm-related headaches). 2. Non-Pharmacologic: o Headache diary: Encourage the patient to maintain a diary to track headache triggers (e.g., stress, sleep patterns, food, and menstruation). o Cognitive-behavioral therapy (CBT): Refer the patient for stress management and relaxation techniques if stress is identified as a trigger. o Lifestyle modifications:  Ensure proper sleep hygiene (7-8 hours of sleep per night).  Regular exercise (e.g., walking or yoga) to reduce stress and prevent tension headaches.  Adequate hydration and balanced diet. Preventive Therapy: For patients with frequent migraines (>4 days per month), consider preventive treatment: • Beta-blockers (e.g., propranolol 40 mg BID). • Antidepressants (e.g., amitriptyline 10-25 mg PO daily at bedtime). • Anticonvulsants (e.g., topiramate 25 mg PO daily, titrated up). Further Diagnostic Evaluation: • Neurology referral: If headaches worsen despite treatment or if neurological, deficits are noted. • Physical therapy: If there are musculoskeletal components contributing to the headache, such as cariogenic headaches. Follow-up: • Schedule follow-up in 2-4 weeks to reassess headache frequency, severity, and response to treatment. • If symptoms worsen or new red flag symptoms (e.g., persistent vomiting, focal neurological deficits, or worsening headaches) develop, the patient should return immediately for further evaluation, including possible imaging.