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iHuman - Rebecca Fields Pivotal povaas Category Question Response I've been having these really bad headaches over the last few months. | don't have one e pe How can | help you today? now, and haven't had one in about a week, but | thought I'd have it checked out anyway. Just the symptoms that | always have had e HPI Do you have any other symptoms or with these headaches, like nausea and concerns we should discuss? vomiting. There's nothing else | can think of off the top of my head. It's not always the same, but they can last e HPI How long does your headache last? the whole day, like 15 hours. x HPI Where more precisely is the pain in your When | get a headache, it's pretty much on head? the left behind my eye. Often my vision in both eyes gets spotty ‘ before the headache actually comes on. | r HPI panei Rane ‘te femishe Cavell gre Mt kine! of like a bunch of 25 begins? Zaggy flashing lights. My eyes are otherwise okay, It's not like they're swollen or watering or anything. But that's pretty much it. Oh, it's pretty unbearable. When my headaches start, it's a 2 or a3, and it becomes an 8 or even a 10 when it really e HPI How severe (1-10 scale) is your headache? —_ gets going. | just can't do anything when | have one of my bad headaches. They can last up to 15 hours, which means the entire day is shot. | don't have one right now. When they do e Symptom Is this the worst headache of your life? happen, the pain does get pretty bad. They just stink. It helps if | lie down in a dark quiet room and e HPI Does enfin make your headache better 11 19 sleep it off. And, definitely, light and w . noise make the pain worse. What are the events surrounding the start of e HPI your nausea and/or vomiting? The bad headaches. @ HPI poo agg nausea andlor vomiting come Yeah, withthe headaches. That's hard to say. Everything seems pretty e@ HPI How severe is your nausea and/or vomiting? severe when I'm having one of my bad headaches. e ip Does anything make your nausea and/or Yeah, headaches....or the absence of vomiting better or worse? headaches! iHuman - Rebecca Fields Do you now or have you ever smoked or eS i chewed tobacco? Absolutely not. Every now and then | have a glass of red wine at the end of my waitressing shift. e SH Do you drink alcohol? If so, what do you Working part-time and being a graduate drink and how many drinks per day? student can sometimes be stressful. | usually have about 2-3 glasses of red wine a week. They're maybe about 6 oz each. © SH Do you use any recreational drugs? If so, Maybe a little marijuana in the past, that's what? ail. Nothing lately. e | Symptom Do you have any sensitivity to light? When | have the headaches. Yes, definitely. roy Symptom Do you have ringing in your ear(s)? No. e Symptom Are you short of breath? No. Do you have unusual heartbeats e Symptom (palpitations)? No. e Symptom Do you have any pain in your chest? Nope. I e@ ‘Symptom Does your chest feel tight or heavy? Nope. Do you have any tingling and/or numbness e Symptom anwhore? iy aingting I don't think so. e Symptom Do you have a dizziness problem? No. oa Symptom Do you have a dizziness problem? No. Over the past two weeks, how often have e Symptom you been bothered by feeling down, Don't have that problem. depressed, or hopeless? In addition to the relevant problem-focused questions mentioned above, communication techniques promote rapport-building land unbiased data-gathering during the patient's history. Examples of key techniques in this case include: @ Performed X Missed ‘Pivotal Concept Category Question Response Addressed Well, | can't work or study when | have one of my bad headaches, and | usually have to sleep the headache off. It's really messing e Comm What symptom is the most distressing for with both my school and work you? responsibilities. And | know this might sound crazy, but I'm afraid it might be something really serious; you know, like a slowly growing brain tumor. Family History: No children. Father’s history unknown. Mother is living and experiences similar headaches. Preventative Health: Immunizations up to date. Received COVID-19 and annual 4#u shot. Diet consists of a “regular American diet" and reports eating chocolate and cheez-its. Does not adhere to an exercise regimen beyond “running around" while waitressing. HPI: P.S. is a 26-year-old female graduate student who works part-time waitressing. Headaches range in severity of 2-3/10 up to 8-10/10 lasting up to 15 hours. Reports experiencing headaches since 10 years of age. Headaches are associated with nausea, vomiting, photophobia, and phonophobia. Denies any head/bodily traumas or injuries. Headaches are relieved with OTC Acetaminophen 325-650 mg or ibuprofen 200-400 mg as needed and with sleep, quiet, and darkness. Reports Mother has experienced similar headaches. Reports stress related to work and school. General: HEENT: Denies any traumas or injuries. Reports photophobia, phonophobia, and "zig-zagging” ashing lights with the onset of headaches. Headaches range in severity of 2-3/10 up to 8-10/10 lasting up to 15 hours. Denies issues swallowing. Cardiovascular: Denies hypertension, palpitations, chest pain, tightness, or heaviness. Respiratory: Denies cough, SOB, or chest pain. Gl: Experiences NV with headaches. Denies heartburn or issues swallowing. Denies constipation or diarrhea. Diet consists of a "regular american diet” and reports eating chocolate and cheez-its. GU: Denies problems with menstruation. Reports a “little” abdominal bloating, back pain, weight gain, or mood change before the start of menstruation. Denies pain or discomfort with urination. Musculoskeletal/Osteopathic Structural Examination: Denies joint/bone pain, muscle pain or cramping, or swelling. Neurologic: Reports intermittent headaches, 2-3/10 up to 8-10/10 lasting up to 15 hours with associated photophobia, phonophobia, nausea, and vomiting. Denies trouble concentrating or focusing. Denies numbness/tingling, generalized weakness, dizziness, or seizures. Integumentary/Breast: Denies rash, skin itching or burning, or skin sores with color change. Cardiovascular: S1, S2 present, regular rate and rhythm. No murmurs, gallops, or rubs noted. Carotid arteries regular rate and rhythm to auscultation. JVP less than 3 cm above sternum. PMI is quarter sized, brisk, and tapping, palpated at 5th ICS and MCL. Capillary reliill less than 3 seconds. No swelling, pallor, hair loss, lesions, or ecchymosis if bilateral lower extremities. Chest/Respiratory: Respirations even and unlabored. Lung sounds clear to auscultation in all [Shields bilaterally. No lifts or accessory muscle use. No scars, moles, rashes, erythema, or ecchymosis. Upon palpation no tenderness, masses, heaves, thrills, or crepitus. Upon percussion all anterior lung lHiiields are resonant. Left anterior chest/heart and right lower chest/liver dull to percussion. Sensation is intact to pain and light touch at thorax and back bilaterally. Abdomen: Abdomen is non-distended with no scars, moles, masses, rashes, erythema, or ecchymosis. Bowel sounds are normoactive and present in all four quadrants. Liver is 8 cm at midclavicular line, edge palpable just below costal margin. Spleen is not palpable. GU/Rectal: Not assessed. Musculoskeletal: Full and painless ROM in [/#exion, extension, lateral bending and rotation bilaterally of all extremities. Extremities without rashes, lesions, erythema, swelling or echymosis and no fasciculations or loss of muscle bulk. Lower extremities no hair loss, varicosities, or cyanosis. All extremities Active ROM full and painless, 5/5 bilaterally, painless upon lJ#exion, extension, internal rotation, external rotation, adduction, and abduction bilaterally. Neurologic: Gait steady. Movements of hands and lingers to the nose are smooth, quick, and coordinated bilaterally. Movements of the heel to shin smooth, quick, and coordinated bilaterally. Negative Romberg test and no pronator drift. 3/3 registration and recall. Attention intact. Names 2/2 objects accurately. Able to follow multi-step commands. Spatial and executive function intact on drawing task. MMSE 30/30. Negative Brudzinski’s and Kernig’s signs. DTRs 2+ bilaterally. Negative babinski’s test. Sensation to light touch/pain intact bilaterally. Sensation intact bilaterally to vibration, proprioception, and temperature bilaterally. Psych: Skin: Skin warm, dry, with no lesions. Skin turgor of back of the hand snaps back rapidly. Nails without ridging, pitting, or peeling. iHuman - Rebecca Fields Physical Exam Guidance Key elements in this patient's physical examination include the following: + Gait is part of a good neurological exam, which is essential for a patient with a concem of new or changing headache. It acts a gross screening for cerebellar dysfunction. Given the patient's age and relative health, more specific cerebellar examination techniques were not required for this case. + The remainder of a screening neurologic examination for a patient with progression in headache frequency includes cranial nerve testing, resisted range of motion (strength) testing, sensation testing (pain and light touch), and reflexes. Checking each of these areas allows the clinician to guage any findings against a screen of the full nervous system's function. + Ina patient presenting with new onset headaches or progression in the frequency of headaches, it is important to evaluate for signs of trauma. Thus, head and neck inspection should be completed. + Headaches may be caused by upper respiratory issues, so evaluation of the ear canals, TMs, nose, pharyngeal mucosa, sinuses, cervical lymph nodes, and Kernig's and Brudzinski's tests is warranted. + Auscultate vital organs to ensure overall patient health. 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 scotomas and associated nausea and vomiting with headaches, photophobia, and phonophobia. Her vital signs and physical exam are non-contributor Keep a headache diary to record frequency and characteristics of migraines. Sumatriptan should not be used for more than 10 days per month, notify your HCP if so, as it may exacerbate headaches (Drugs.com, 2023). Drowsiness may occur with Sumatriptan, do not operate heavy machinery or drive until you know how it affects you or avoid it altogether (Drugs.com, 2023). Regarding metoclopramide, notify your HCP if you have problems with muscle movements, liver or kidney disease, seizures, breast cancer, diabetes, depression or mental illness, congestive heart failure or a heart rhythm disorder, or Parkinson’s disease (Thornton, 2023). Discontinue metoclopramide if you are pregnant or breastfeeding, consult your HCP if this may be a concern (Thornton, 2023). Do not drink alcohol with metoclopramide as it may increase side effects (Thornton, 2023). Incorporate lifestyle modilfications that reduce stress including a healthy diet that is avoidant of caffeine, alcohol, and junk foods with water being your primary source of hydration (American Headache Society, 2021). Incorporate an exercise regimen, even as little as walking, or consider wellness alternatives such as mindfulness, yoga, and/or meditation (American Headache Society, 2021). Establish a consistent eating pattern and avoid skipping meals to avoid the onset of headaches brought on by an inconsistent eating routine (American Headache Society, 2021). Promote effective sleep by reducing exposure to artilficial light before bed and engaging in relaxing activities before bedtime such as a bath, self-massage, reading, light conversation or journaling to prevent migraines and headaches (American Headache Society, 2021). Follow-up: Follow up with the office in one month to consider the e#icacy and frequency of Sumatriptan as well as for the need for any referrals (Tzankova et al., 2023). Notify your HCP if you experience any problems with muscle movements, change in characteristics of urination, have feelings of depression or other mental illness, palpitations, rash, or seizures (Drugs.com, 2023). Go to your nearest emergency room or call 911 if you experience signs of a severe allergic reaction including swelling of the airway and ditculty breathing with medication use (Drugs.com, 2023). References American Headache Society. (2023). Lifestyle recommendations for migraine patients. American Headache Society. iHuman - Rebecca Fields 
