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

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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

• Head: no visible scariness, edema, masses, lumps, or deformed – non tender

• Eyes: eyelids- no ptosis, erythema, or swelling, conjuncvae pink with no discharge. Scleral anicteric, orbital area—no edema, redness, or tenderness noted. No extra ocular eye movement. PERRLA

• Ears: normal appearing external structures, no deformers or edema, no discharge noted. Tympanic membrane pearly gray without erythema, building or loss of landmarks bilaterally.

• Nose: no discharge or polyps noted. No deviated septum, edema, or tenderness over the frontal and maxillary sinuses.

• 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

• Have you had any significant trauma injuries or accidents? – No I have not... never been knocked out or anything like that

• Are you taking any prescription medications? – no

• Are you taking any OTC or herbal medication? – Some mess Benadryl for sleep around nails me. I take acetaminophen or ibuprofen some mess for some of my HA

• Do you drink capitated beverages or eat chocolate? – I like chocolate. I guess my only real vice.

• Maybe I overdo it a bit

• Do you drink alcohol? If so, what do you drink and how much drink per day? – Every now and then I have a glass of red wine at the end of my waitressing shy. Working pare and being grade student can some mess be stressful. I usually have 2-3 glasses of wine a week; they may be about 6 oz. each

• Do you use any recreate oral drugs? If so what? – Maybe a like marijuana in the past, that is all. Nothing lately

• Do you have new HA that you have not experienced previously? – Not really. I have been having HA every 1-2 months for the past 10 years, but the past few months there happening more frequently. Like every 1-2 weeks, which is why I am here. The pain is also worse

• Do you feel confused at mess? – like, with my bad HA, not really

• Do your HA occur when your canine intake change? – I do not know. I don’t have that much canine on a daily basis

• 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 photophobia.

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. Cariogenic headache : Originating from the cervical spine,

often worsened by neck movement.

5. Secondary causes : Tumor, aneurysm, or infection (requiring

imaging for confirmation).

TEST RESULTS

• Complete Blood Count (CBC) : [Insert values, focus on anemia or

infection]

• 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.

 Trip tans for suspected migraines (e.g., sumatriptan 50

mg PO).

 Antiemetic’s 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 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