WEEK #9: I-HUMAN CASE 26-YEAR-OLD FEMALE REASON FOR ENCOUNTER MORE FREQUENT SEVERE HEADA, Lab Reports of Integrated Case Studies

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WEEK #9: I-HUMAN CASE 26-YEAR-OLD

FEMALE REASON FOR ENCOUNTER

MORE FREQUENT SEVERE

HEADACHES UPDATED ON DECEMBER

2024 ALREADY GRADED A

lOMoAR cPSD| 22080904 lOMoAR cPSD| 220

• Bebe

• 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.
• Primary Diagnosis: Tension headaches or migraines

ASSESSMENT

(differentiating between the two may depend on further history and testing).

• Differential Diagnoses:
  1. Migraine: Unilateral, pulsating headache with associated nausea, photophobia, and phonophobia.
  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. Cervicogenic headache: Originating from the cervical spine, often worsened by neck movement.
  5. Secondary causes: Tumor, aneurysm, or infection (requiring imaging for confirmation).
• Complete Blood Count (CBC): [Insert values, focus on anemia or infection]
• Electrolytes and Glucose: [Insert relevant findings,

TEST RESULTS

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]

1. Acute Management: (^) o Pharmacologic:  NSAIDs (e.g., ibuprofen or naproxen) or acetaminophen for mild headaches.  Triptans for suspected migraines (e.g., sumatriptan 50 mg PO).  Antiemetics if nausea is present (e.g., ondansetron 4 mg PO). o Preventive therapy for frequent migraines may

PLAN

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 cervicogenic headache is suspected.

Would you like to modify any specific sections or add more details? 4o You said: more details ChatGPT said: ChatGPT Here’s a more detailed breakdown of the case, expanding on each section including further treatment options and additional considerations for testing and differential diagnosis.

• Name: [Insert Patient Name]
• Age: 26 years old
• Gender: Female
• Height: 5'6" (168 cm)
• Weight: 122 lbs (55.5 kg)

PATIENT DETAILS

• Location: Outpatient clinic
• Reason for Encounter: Increased frequency and severity of headaches
• 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: Normocephalic, atraumatic. o Eyes: No evidence of scleral icterus or conjunctival injection. Extraocular movements intact, pupils equal, round, reactive to light (PERRL). No papilledema observed on fundoscopic exam. o Ears/Nose/Throat: No sinus tenderness. Tympanic

PHYSICAL EXAM FINDINGS

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.
• Primary Diagnosis:^ Migraine without aura, based on the nature of the headache (severe, throbbing, and episodic), associated symptoms (nausea, photophobia), and worsening frequency.
• Differential Diagnoses:
  1. Tension-type headache: Headache described as bilateral, pressing, or tightening in quality, often associated with stress or poor posture.
  2. Cluster headache: Typically presents with unilateral periorbital pain, associated with lacrimation and nasal congestion.
  3. Cervicogenic headache: Headache originating from the cervical spine, associated with neck pain and stiffness, often worsened by neck movement.
  4. Medication overuse headache: Seen in patients who use acute headache medications (e.g., NSAIDs, triptans) frequently.

ASSESSMENT

5. Intracranial mass or hemorrhage: Less likely but should be ruled out if headaches become progressively worse or if associated with neurological deficits.
6. Sinusitis: If there’s any associated facial pain or pressure, and tenderness over the sinuses. To rule out secondary causes and confirm the diagnosis of migraine, the following tests may be considered:

• Basic Blood Work: o Complete Blood Count (CBC): Normal white blood cell count (no signs of infection), normal hemoglobin and hematocrit (rule out anemia). o Electrolyte Panel: Sodium, potassium, calcium, and glucose levels within normal limits.
• Thyroid Function Tests: o TSH: Within normal range to rule out hypothyroidism, which can occasionally present with headache.
• Neuroimaging: o MRI Brain: Recommended if the patient has any red flag symptoms, such as new-onset severe headaches in a patient over 50, neurological

TEST RESULTS