Headache Case Study
Patients ID: Mrs. GG,
Age: 62 years,
Race: Hispanic,
Gender: Female,
Date of Birth: October 23rd, 1959,
Marital Status: Married.
CC: “I’ve been suffering from terrible headaches for the last five days. The headaches are so severe that they make me feel nauseated.
History of Present Illness: Mrs. GG, aged 62 years, is a Hispanic woman who comes to the facility with terrible headaches. Her severe headache had lasted about five days. She added that migraines make her agitated, thus she felt the need to see a doctor. The lady said she hadn’t had similar symptoms since campus. She reported the migraine pain as strong, a 9/10 on a pain scale, with a pounding feeling in her temporal area. Her discomfort began a couple months earlier and has steadily worsened. She said that she tried using ibuprofen to ease the discomfort, but it is no longer working. she says that she feels better in chilly, quiet, dim settings, but worse in noisy, bright locations. This has prevented her from watching her favorite TV show.
Review of Systems
Constitutional: The patient states no other concerns and reports to be absolutely well apart from the headaches.
HEENT: Head; experiences a pounding feeling on her left temporal area due to intense headaches. Standing uneasiness and sensitivity to brightness and strong music are symptoms of the illness. Eyes; sometimes, he has double vision and patches. Ears; she denies deafness and Nose; denies epistaxis nasal congestion, postnasal drainage and running nose Mouth and throat; Painful throat, nodes, inflamed nodes, and cold symptoms are all denied. Denies the existence of gum disease and dental abnormalities.
Skin: Skin sores, bruising, irritation, ulcers, and skin colour changes are all denied
Pulmonary: Denies having respiratory problems, wheezing, coughing, or obstruction..
Cardiovascular: the client denies shortness of breath with exertion, chest pain unusual
heartbeats and heart problems
Gastrointestinal: patient reports nausea associated with the headaches, without vomiting. n other gastrointestinal concerns
Genitourinary: Patient does not report any concerns like changes in urine, frequency, odour and urgency. she denies abnormal vaginal discharge or itching around the genitals
Musculoskeletal: she denies Injury or traumas, joint weakening or rigidity, muscular spasms, inflammations, or discomfort in the limbs. Spinal pain or ache is also denied.
Lymph/Hematologic: She denies inflammation of the lymph nodes, or bruising and bleeding
easily.
Neuro/Psych: Denies having suicidal thoughts, insomnia, or anxiety. she reports severe headaches that cause her to be nauseated
Past Medical History: The client stated she had no severe health issues. she was hospitalised twice for the delivery of her two sons
Surgical: Underwent two surgeries at the age of 26 years and 29 years to deliver her sons
Allergies: She states that she has no hypersensitivity reactions
Medications: over the counter Ibuprofen 400mg but has stopped
Immunization: Her vaccinations are up to date.
Family History: Paternal grandparents died of old age difficulties but had no illnesses. Her maternal grandparents died. The grandpa had Alzheimer’s, but the grandmother had no illness. The mother is 90 years old and has high blood pressure. Her father succumbed aged 90 owing to Alzheimer’s problems. Her 72-year-old spouse is still living and well. Their sons, ages 39 and 42, are healthy and living.
Social History: The client lives in Los Angeles California with her spouse, two grandkids, and two housekeepers. She retired from her job as a US Marine at the age of 60. Her spouse was an engineer but is now retired. They have a good financial position. She denies using tobacco or narcotics. The patient only consumes wine during social and special gatherings. Her hobbies include swimming, running, and yoga, but her migraines have prevented her from doing so. Her diet is good and she follows her nutritionist’s advice. The client is a devout Christian who attends service regularly.
OBJECTIVE DATA
Vital Signs: Pulse: 79, Temperature: 97.9 ℉, Respiratory Rate: 17, Oxygen saturation: R.A 99%, Blood pressure 119/80, Height 5’.5’, Weight 128 lbs, BMI 19.6.
General: the patient is in good health, awake, and oriented. The nervous, disturbed woman sits erect. Her answers are succinct and rational, she reported of severe headaches.
HEENT: normocephalic, has a uniform hair spread on her skull. Her right temporal area is hurting from a severe headache. Eyes; No sinus pain, clean conjunctivitis, and visits an optometrist regularly. Ears: Preserved symmetrical cerumen; no pinna or tragus anomalies; no discomfort or ear canal irritation. Throat and Mouth; Optimal dental development with white teeth, healthy gums, and no ulcers or tumours
Neck: No lymphadenopathy or carotid bruits were seen in the trachea. Her neck is throbbing with a little pain that extends along her neck.
Pulmonary: Respiration rate is within normal range, and respirations are unlaboured. the lungs are clear on auscultation, without abnormal sounds like wheezing.
Cardiovascular: the pulse rate is normal, and the heart beat has a regular rhythm. capillary refill is two seconds. no oedema noted. no gallops or frictional rubs noted on chest auscultation
Gastrointestinal: Bowel sounds are present and normal on all quadrants. no hepatosplenomegaly on palpation. abdominal tenderness is also absent. nausea without vomiting
Genitourinary: palpable nondistended bladder noted. perinium is clean, odourless. no discharge from the genitalia. no tumours or lesions observed around the external genitalia.
Musculoskeletal: uninflamed joints, without pain or stiffness. no muscle tenderness or pain.
Neurologic/Psych: Her voice was smooth and rational, and she responded to questions with a rational tone. She didn’t have any odd reflexes, either. She is attentive and focused, and her responses to questions are appropriate.
ASSESSMENT
Differential Diagnoses
Differential Dx: Migraines: – They are intense headaches that cause pounding or pulsating on one side of the head. The attacks are coupled with nausea, vomiting, and increased sensitivity to lights and noises (Becker, 2017). Migraine episodes are intense and can linger for days or weeks, disrupting normal operations. The disorder is age-neutral, affecting people of all ages (Becker, 2017). The client has a pounding pain in her temporal region that has become worse recently. The patient also has light and sound sensitivity.
Differential Dx: Cluster Headaches: – Are considered to be terrible because they cycle. Cluster headaches cause severe discomfort over one eye or one side of the head throughout the night. The assaults might span weeks or months, with recovery intervals amongst episodes. The recovery phases range from months or even years. The headaches are uncommon and harmless. They cause agitation, discomfort excessive crying, erythema in the afflicted eye, pale skin, and a congested nose (Goadsby et al., 2018). Staring may cause cluster headaches. The alternative is ruled out because the client did not disclose a runny nose, ocular inflammation or erythema, or eyelid drooping.
Differential Dx: Viral Meningitis (ICD-10-CM-A87.9) – The most prevalent kind of meningitis is viral meningitis. It is triggered by non-enteroviruses, influenza, mumps, herpes, and measles, (Brouwer & Van de Beek, 2017). Symptoms include rashes, nausea, vomiting, insomnia, light sensitivity, and neck stiffness (Brouwer & Van de Beek, 2017). There was no history of neck rigidity, vomiting, drowsiness or fever, and no record of sexually transmitted illnesses like herpes virus, therefore the differential is ruled out
Final Differential: Migraines (ICD-10-CM-G43.909) – This woman has migraine because her symptoms closely match those of a migraine (Becker, 2017). She had a strong headache and pounding pain in her temporal region (Becker, 2017). The blood work and urinalysis revealed no pathogens or other pathologies like hyperglycaemia or thyroid issues, confirming the migraine diagnosis. The client had no head traumas or neurological infections, according to imaging scans.
PLAN
DIAGNOSTIC LAB:
The application of neuroimaging, Computed tomography, and Magnetic resonance imaging is based on the health background and physical exam of the client.
Laboratory test: A urine drug test may help rule out opioids and illegal drugs abuse. ESR, CBC and TSH are also advised. (Cash et al., 2017).
Blood chemistry and urinalysis: To exclude other illnesses that might cause headaches, such as hyperglycaemia, infections, and thyroid issues
TREATMENT PLAN AND EDUCATION
When migraine complaints like headaches, nausea, or vomiting appear, the client can be given Sumatriptan 50mg, (UpToDate, 2020). If the signs continue, the client may take an additional pill two hours later. A doctor should be consulted before getting another dosage. Overdosing on Sumatriptan (200mg) in 24 hours is not advised due to harmful effects (UpToDate, 2020). Sumatriptan is a selective serotonin receptor agonist that works well for mild to moderate migraines (UpToDate, 2020). Mild to moderate migraines respond well to NSAIDs and Tylenol. It must not be used with other selective serotonin receptor agonists.
FOLLOW-UP: she should return after two weeks for evaluation
Referral: Patient will be referred to a neurologist in case symptoms do not recede. (Cash et at., 2017).
References
Becker, W. J. (2017). The diagnosis and management of chronic migraine in primary care. Headache: The Journal of Head and Face Pain, 57(9), 1471-1481. https://doi.org/10.1111/head.13089
Brouwer, M. C., & Van de Beek, D. (2017). Viral Meningitis: Epidemiology, diagnosis, and treatment of brain abscesses. Current Opinion in Infectious Diseases, 30(1), 129-134. https://doi.org/10.1097/qco.0000000000000334
Cash, J. C., Glass, C. A., & Mullen, J. (2017). Family practice guidelines (4th ed.). Springer Publishing Company.
Goadsby, P., Wei, D., & Yuan Ong, J. (2018). Cluster headache: Epidemiology, pathophysiology, clinical features, and diagnosis. Annals of Indian Academy of Neurology, 21(5), 3. https://doi.org/10.4103/aian.aian_349_17
McLaren, D. (2021). Headaches and migraines: Medication overuse headache-a difficult pill not to swallow. AJP: The Australian Journal of Pharmacy, 102(1206).
UpToDate. (2020). UpToDate. Retrieved December 3, 2021, from https://www.uptodate.com/contents/acute-treatment-of-migraine-in-adults
