iHuman Perry Soloman Notes - Week 6: Case Study of a Graduate Student with Headaches, Assignments of Nursing

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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 昀氀 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" 昀氀 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. GI: 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.

cervical spine in 昀氀 exion, extension, lateral bending, and rotation bilaterally. Symmetric muscle movement without weakness bilaterally. No pain with cervical compression/Spurling test.

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 re 昀椀 ll 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 昀椀 elds 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 昀椀 elds 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 昀氀 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 昀氀 exion, extension, internal rotation, external rotation, adduction, and abduction bilaterally. Neurologic: Gait steady. Movements of hands and 昀椀 ngers 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/ 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.

Lymphatic: Cervical nodes mobile, non-tender, pea-sized, and soft bilaterally. Thyroid without mobile masses, tenderness, nodules, or enlargement. Statement: P.S. is a 26-year-old female graduate student who presents today with a chief complaint of worsening intermittent headaches which have occurred since she was 10 years old. HA is also associated with nausea, vomiting, photophobia, and phonophobia. Severity of headache ranges up to 8-10/10 pain scale. Headaches are localized behind the left eye & can last a duration of up to 15 hours. P.S. reports stress from work and school and indulging in wine, chocolate, and junk food. Headaches are relieved by sleep, lying in a dark room, and OTC Acetaminophen 325-600 mg or ibuprofen 200-400 mg. FMH is positive for the patient’s Mother also experiencing similar headaches. P.S. reports headaches severely impacting her daily life, and work, where she is a waitress. SH is also positive for past marijuana use. Physical examination reveals vital signs WNL, normal ROM and all DTRs present and normal with a unremarkable neurological exam.

Diagnosis: migraine with aura

Client Education:

• Do not use sumatriptan prophylactically to prevent migraines, but, take it as soon as possible with the onset of migraine or cluster headaches and associated symptoms (Drugs.com, 2023). Do not take a second dose without consulting an HCP (Drugs.com, 2023).

• 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 modi 昀椀 cations 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 arti 昀椀 cial 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 o 昀케 ce in one month to consider the e 昀케 cacy 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).

https://americanheadachesociety.org/wp-content/uploads/2022/05/AHS-First- Contact-Lifestyle-Recommendations.pdf Drugs.com. (2023). Sumatriptan dosage. https://www.drugs.com/dosage/sumatriptan.html Thornton, P. (2023). Metoclopramide. Drugs.com. https://www.drugs.com/metoclopramide.html Tzankova, V., Becker, W.J., Chan, T.L.H. (2023). Diagnosis and acute management of migraine. CMAJ. 195 (4). E153-E158. https://doi.org/10.1503/cmaj. This document is made available for students merely for even better practice, preparation and brainstorming purposes.