WEEK#9:I-HUMANCASE26-YEAR-OLD Best Reviews I Human Casestudy Week #9 26 Year Old Female Re, Exams of Nursing

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WEEK#9:I-HUMANCASE26-YEAR-OLD

Best Reviews I Human Casestudy Week

26 Year Old Female Reason For Encounter:

Frequent Severe Headache

Location;Outpatient Clinic Case Study{

COMPLETE AND VERIFIED}

PATIENTDETAILS

• Name

• Age:26yearsold

• Height:5'6"(168cm)

• Weight:122lbs(55.5kg)

• Location:Outpatient

clinic

• ReasonforEncounter:

More frequent severe

headaches

• lOMoARcPSD|220 80904

• Head:novisiblescaliness,edema, masses,lumps,ordeformi琀椀 es – nontender

• Eyes: eyelids- no ptosis, erythema, or swelling, conjunc 琀 椀 vae pink with no discharge. Sclerae anicteric,orbitalarea—noedema, redness,ortendernessnoted. Noextraoculareyemovement. PERRLA

• Ears:normalappearingexternalstructures,nodeformi 琀椀 esoredema,nodischargenoted. Tympanic membrane pearly gray without erythema, building or loss of landmarks bilaterally.

• Nose:nodischargeorpolypsnoted.Nodeviated septum,edema,ortendernessoverthefrontal and maxillary sinuses.

• Throat: trachea midline, no erythema, lesions, or deformi 琀椀 es. No cervical paraspinal musclestendernesstopalpa 琀 椀 on. Nomassorregionallymphadenopathy. Thyroidmoves with swallowing.
• Respiratory: symmetricalexpansionandanterior-posterior(AP)diameterisnormal. Noadven 琀椀琀椀ousbreathsoundsoruseofaccessorymuscles. Nocrepitus,tenderness, thrills,orrashes noted anterior or posterior of chest. Lung sounds clear to ausculta 琀椀 on.
• Cardiac:NosignsofJVD, heartpalpita 琀 椀 onormurmurs. S1, S2notedwithregularrateand rhythm.
• Abdomen: is 昀氀 at and symmetric with no scars, deformi 琀 椀 es, striae, or lesions. Bowel soundsarenormoac 琀椀 ve. Nopain, tenderness,masses,orpulsa 琀 椀 ons. Noguardingor rebound tenderness. No signs of hepatosplenomegaly. Liver span normal and spleen is no palpable.
• Musculoskeletal: No swelling or deformi 琀 椀 es, no cyanosis, edema, or clubbing noted on extremi琀椀 es. Notenderness,muscularresistanceorrigidity.Strengthintactbilaterallyin upper and lower extremi 琀椀 es.
• Neurologicalexam:
• Balancetest-Gait intact
• Pointtopointtestarms (昀椀 ngertonose): 昀椀 ngertonoseintactbilaterallywithoutpast- poin 琀椀 ng
• Point-to-pointtestleg(heeldownshin): heeltoskinintactbilaterallywithoutpast-poin琀椀 ng
• Rapidalterna 琀椀 ngmovement-昀椀 nger: rapidalterna 琀椀 ngmovementathandsintact bilaterally
• Romberg’sandpronatordri昀琀 stest- nega琀椀 veRombergtest,nopronatorsdri昀琀
• Re 昀氀 exesdeeptendon – triceps,biceps,brachioradialis,knee/patella, ankle/achilles – 2 bilaterally
• GU:normal.Nomassesortenderness,normalpelvicexam
• Rectal: novisible昀椀 ssures,indura琀 椀 onor lesion

• Bebe Babbi琀琀 s26y/ofemale
• 5’6’’122lbs
• Reasonforencounter:Morefrequentsevereheadaches
• How can I help you today? – Ive been having these really bad headaches over the last few months.Idon’thaveonenowandhaven’thadoneinaboutaweek,butIthought I’dhaveit checked out anyway.

thesymptomsthatIalwayshavehadwiththeseheadaches, likenausea

and vomi 琀椀 ng

study when I have one of my bad headaches, and I usually have

tosleeptheheadacheo 昀昀. Itsreallymessingwithbothmyschoolandwork responsibili 琀椀 es. And I

know this might sound crazy, but imafraid it might be something

really serious, you know. Like a slowlygrowing brain tumor

inadarkroomandtrytosleepito 昀昀. Andde 昀 椀 nitelylightandnoise

make the pain worse

whenivebeenea 琀椀 ngjunkfood pre 琀 琀 ymuchonthele 昀琀 behindmyeye

doesn’tmove anywhere else

my HA starts, it’s a 2 or a 3 and it becomes an 8 or even 10 when

itreallygetgoing. IjustcantdoanythingwhenIhaveoneofmybadHA.They

can last up to 15 hours which means the en 琀 椀 re day is shot

• NoHAatnight
• Sleephelps
• Howquicklydose yourHAcome on?– onceitstriggered,itsteadily

increases.Itsnotlikeawhackoftheheador anything.

happenwhenIhaven’tbeensleepingenough.Ihavebeenhaving

• Howsevere ( 1 - 10 ) isyourHA? – ohit’spre 琀 琀 yunbearable. When
• Whenmorepreciselyisthepaininyourhead? – whenIget aHA,its
• Whatdoesthepaininyouheadfeellike?–throbbing
• DoseanythingmakeyourHAbe 琀 琀 erorworse?- ithelpsifIliedown
• Doyouhaveanyothersymptomsorconcernsweshoulddiscuss?– just
• Whatsymptomisthemostdistressingforyou? – well,Ican’tworkor
• DoanyfoodseemtobringtheHA on?–well,Iseemtogetthem more
• Doesthepaininyourheadradiatesomeplaceelse?Where?–noit
• Isthereanypa 琀 琀 erntowhenyourHAoccurs? – theyusually

troublewithsleepanddrinkingmoreredwinerecentlygivenallmystress

the HA begins? – o 昀琀 en my vision in both eyes get blurry at theedgesbeforetheHAactuallycomeson. Icans 琀 椀 llsee;

itskindoflikeathinveil.

Myeyesotherwiseokay;itsnotlikethey’reswollenorwatering or anything.

My vision is just blurred. But that’s pre 琀 琀 ymuch it seen by a doctor for this. I use acetaminophen but by the 琀 椀 me

Itake it. I can’t keep it down because I am so nauseated. Same

withibuprofen.

Acetaminophenandibuprofenusedtoworkbutnowtheyreally don’t help

notmuchtotell. Theusuallychildhoodstu 昀昀 椀 onorge 琀 ngangrypalpita 琀 椀 on?

• – no
• Doyouhaveanyallergies?–no
• Areyourimmuniza 琀椀 onuptodate? – Ithinktheyhadtobein

ordertostartgradschool. Ialsogotmycovid-19vaccineseriesandannual

昀氀 u shot

• Haveyouhadanysigni 昀 椀 canttrauma 琀 椀 cinjuriesoraccidents? –

noIhavenot..neverbeenknockedoutoranythinglike that

• Areyoutakinganyprescrip 琀椀 onmedica 琀椀 ons? – no
• Are you taking any OTC or herbal medica 琀 椀 on? – some 琀椀

mesBenadrylforsleeparound 昀 椀 nals 琀椀 me.

Itakeacetaminophenoribuprofen some 琀椀 mes for some of my HA

• Doyoudrinkca 昀 昀 einatedbeveragesoreatchocolate? – Ilike

chocolate.ItsmyonlyrealviceIguess.

• Canyoutellmeaboutanycurrentorpastmedicalproblemyouhad?–
• Whattreatmentshave youhadforyouHA?-well,Ihaven’treallybeen
• Doyouhaveanyawarenessorwarningsymptomsthatoccurs before
• Doyouexperiencechestpaindiscomfortorpressure;painwithexer 琀

• MaybeIoverdoitabit
• Doyoudrinkalcohol?Ifso,whatdoyoudrinkandhowmanydrinkperday? –

every now and then I have a glass of redwine at the end of my

waitressingshi 昀琀. Workingpar 琀 meandbeinggradstudentcansome琀椀

mesbestressful.Iusuallyhave2-3glassesofwineaweek;theymaybeabout6oz each

• Doyouuseanyrecrea 琀 椀 onaldrugs?Ifsowhat? – maybeali 琀 琀 le

marijuanainthepast,that’sall.Nothing lately

• Do you have new HA that you have not experienced previously? – not really.

Ihave been having HA every 1-2 months for the past 10 years, but the past

fewmonthstheyrehappeningmorefrequently.Likeevery1-

2weeks,whichiswhyIam here. The pain is also worse

• Doyoufeelconfusedat 琀椀 mes? – like,withmybadHA, notreally
• DoyourHAoccurwhenyourca 昀 昀 eineintakechange? – Idon’tknow. Idon’thave

that much ca 昀 昀 eine on a daily basis

•

• Treatmentformigraineswithaura

PHYSICALEXAMFINDINGS acutedistress.

• General:Patientappearswell-nourishedandinno
• VitalSigns: o BloodPressure:[Insert value] o HeartRate:[Insert

Temperature:[Insertvalue] [Insertvalue] motorstrengthinallextremities. papilledemaobserved. orrubs. crackles. value] o RespiratoryRate: [Insertvalue] o o OxygenSaturation:

• HeadandNeck:Notraumaordeformities.Neckis supplewithoutlymphadenopathyorthyromegaly.
• Neurological: o CranialnervesII-XIIintact. o Normal o Deeptendonreflexesarenormaland symmetric. o Nosensorydeficitsnoted. o Gaitisnormal.
• Eyes:Pupilsareequal,round,andreactivetolight.No
• Cardiovascular:Heartsoundsareregular,nomurmurs
• Respiratory:Lungsareclearbilaterally,nowheezesor
• Abdomen:Soft,non-tender,nohepatosplenomegaly.

ASSESSMENT (differentiatingbetweenthetwomaydependonfurther history and testing).

1. Migraine:Unilateral,pulsatingheadachewitha ssociated nausea, photophobia, andphonophobia.
2. Tension-type headache: Bilateral,pressing/tighteninginquality,withoutsig nificantnausea or vomiting.
3. Cluster headache: Unilateral, severe periorbitalpain,oftenassociatedwithlacrimationa ndnasalcongestion.
4. Cervicogenic headache: Originating from thecervicalspine,oftenworsenedbyneckmovement .
5. Secondarycauses:Tumor,aneurysm,orinfection(r equiring imaging for confirmation). TESTRESULTS

• PrimaryDiagnosis:Tensionheadachesormigraines
• DifferentialDiagnoses:

anemiaorinfection] includingabnormalitiesinsodium,potassium,orbloodglucose] applicable] areabnormalitieslikemassesorhemorrhages] abnormalities. performed,focusonCSFresults] PLAN

1. Acute Pharmacologic: acetaminophenformildheadaches.

• CompleteBloodCount(CBC):[Insertvalues,focuson
• ElectrolytesandGlucose:[Insertrelevantfindings,
• ThyroidFunctionTests(TFTs):[Insertresults,if
• BrainImaging(CT/MRI):[Indicateifnormalorifthere
• Electrocardiogram(ECG):Normalsinusrhythm,no
• LumbarPuncture(ifindicated):[Insertfindingsif Management: o  NSAIDs(e.g.,ibuprofenornaproxen)or

sumatriptan50mgPO). ondansetron4mgPO). include:

2. Non-Pharmacologic: Stressmanagementinterventions,including migrainetriggers(e.g.,caffeine,certainfoods).
3. Follow-Up: symptomsworsenornewneurologicalsignsde velop,immediateimagingwillbeordered(MRI brain, CT head). frequencyandeffectivenessoftreatment. o If biofeedback,cognitive-behavioraltherapy). o  Triptansforsuspectedmigraines(e.g.,  Antiemeticsifnauseaispresent(e.g., o Preventivetherapyforfrequentmigrainesmay  Beta-blockers(e.g.,propranolol).  Antidepressants(e.g.,amitriptyline).  Anticonvulsants(e.g.,topiramate). o MuscleRelaxants:Fortension-typeheadaches. o Encouragerelaxationtechniques(e.g., adequatesleephygiene. o Dietarychangestoavoid o Returnvisitin2-4weekstoreassessheadache