ANSWER
Case 3: Evaluation and Treatment of Headaches
1. Need for More Subjective Information
Other subjective information that should be included in order to more accurately evaluate the patient’s status is:
History of Headaches:
Headaches’ frequency, length, and intensity.
triggers or calming elements other than ibuprofen and sleep.
variations in the pattern of headaches throughout time.
The menstrual cycle
connection to hormonal fluctuations, menstruation, or the use of birth control.
Lifestyle Elements:
stress levels, sleep habits, coffee consumption, diet, and hydration.
Family Background:
any history of migraines or other neurological conditions in the family.
Psychosocial Elements:
history of depression, anxiety, or recent challenges in life.
Use of Medication:
Ibuprofen dosage and frequency, as well as other prescription or over-the-counter drug usage.
2. Other Objective Results to Seek in a HEENT Examination:
To rule out headaches caused by the sinuses, check for sinus soreness.
TMJ palpation for clicking noises or sore joints.
Neurological Assessment:
To identify modest neurological abnormalities, pay attention to muscle strength, balance, and coordination.
Vital Signs:
Keep an eye out for symptoms of high blood pressure, as this may be a factor in subsequent headaches.
Examination of the Eyes:
Check for papilledema, as this could be a sign of elevated intracranial pressure.
3. Ordering Basic Labs for Diagnostic Exams:
CBC: Eliminate anaemia, which may be a factor in headaches and exhaustion.
Tests for Thyroid Function: To determine whether thyroid dysfunction exists.
Imaging Research:
Head MRI or CT: Imaging can rule out structural abnormalities or masses if neurological impairments or red flag symptoms (such as abrupt onset or deteriorating pattern) appear.
Specific Examinations:
Hormonal Panel: To check for menstrual-related hormonal abnormalities.
Electrolytes Panel: To evaluate electrolyte balance and hydration.
Headache Journal:
Ask the patient to record the causes, length, intensity, and related symptoms of their headaches in a journal for one to two months.
4. Differential Diagnoses: Aura-free migraine:
Classic symptoms include light sensitivity, nausea, and pulsatile headache.
This diagnosis is supported by association with menstruation.
Headache of the Tension Type:
Although the pulsatile nature makes this less likely, a headache may be caused by stress or tense muscles.
Cluster Pain:
Unilateral temporal placement is consistent, but the absence of lacrimation or rhinorrhea makes it less plausible.
5. Justifications for Differential Diagnoses: Aura-free migraine
According to Charles (2018), it meets the criteria for the International Classification of Headache Disorders (ICHD-3): it is unilateral, pulsing, exacerbated by exercise, and linked to photophobia and nausea.
Hormonal migraines are suggested by her lengthy history of menstrual-related headaches.
Headache of the Tension Type:
Although it is less common because there isn’t band-like, bilateral pressure discomfort, it is common in females and linked to stress or musculoskeletal strain (Olesen et al., 2018).
Cluster Pain:
Usually shorter in length, more intense, and frequently linked to autonomic symptoms. It remains a disparity in the unilateral presentation.
6. Patient Education for the Treatment of Migraines:
Encourage people to change their lifestyles by eating a balanced diet, staying hydrated, and getting enough sleep.
Recognise and stay away from well-known triggers, such as stress, caffeine, and particular meals.
Use of Medication:
To avoid medication-overuse headaches, don’t take too much ibuprofen. If migraines are verified, prescribe triptans for immediate migraine relief.
Reducing Stress:
Promote methods of relaxation like yoga, mindfulness, or biofeedback.
Follow-up:
Encourage follow-up consultations for additional evaluation and care.
Citations
A. Charles (2018). Clinical management implications of migraine pathogenesis. 174–182 in The Lancet Neurology, 17(2). The publication https://doi.org/10.1016/S1474-4422(17)30435-0
Dodick, D., Olesen, J., and Bendtsen, L. (2018). headache of the tension kind. Neurology, The Lancet, 17(4), 299-306. 10.1016/S1474-4422(17)30469-6 has been published.
Following APA guidelines, this analysis offers a thorough assessment of the patient’s situation. If you would want further information, please let me know!
QUESTION
| Case 3 | |
| Chief Complaint (CC) | “I have been having frequents headaches lately” |
| History of Present Illness (HPI) | A 25-year-old Hispanic female presents to your clinic with a headache located on right temporal area, pulsatile. |
| PMH | Frequent headaches since I was 15, with menses. |
| Drug Hx | Ibuprofen for Headaches |
| Subjective | Light makes headache worst Nausea associated with headaches. No vomiting, Headaches improve usually with rest, ibuprofen, and sleep, but it is annoying to have to sleep all-day |
| VS | B/P 108/64; Pulse 86; RR 16; Temp 98.6; |
| General | 25-year-old female appears well developed and well-nourished, healthy appearing, wearing dark glasses in a dim room |
| HEENT | no injection, anicteric, PERRLA, EOMs intact, without pain to movement; normal vision |
| Lungs | CTA AP&L |
| Card | S1S2 without rub or gallop |
| Abd | benign, normoactive bowel sounds x 4; |
| Rectal exam | Non contributory |
| Integument | intact without lesions masses or rashes. |
| Neuro | Cranial nerves II to XII intact; sensation intact, DTRs 2+ throughout. Functional neurological exam is WNL |
Once you received your case number, answer the following questions:
1. What other subjective data would you obtain?
2. What other objective findings would you look for?
3. What diagnostic exams do you want to order?
4. Name 3 differential diagnoses based on this patient presenting symptoms?
5. Give rationales for your each differential diagnosis.
6. What teachings will you provide?
Submission Instructions:
· Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.