The case study patient assigned to me is a 25-year-old Hispanic female who presents with a chief complaint: “I have been having frequent headaches lately”.
The case study patient assigned to me is a 25-year-old Hispanic female who presents with a chief complaint: “I have been having frequent headaches lately”. The location of the current headache is on the right temporal area and is pulsatile. Light makes the headache worse. Nausea is associated with the headaches. She denies vomiting. The headaches improve with rest, ibuprofen, and sleep. She states that she has had frequent headaches since she was 15 years of age that occur with menses. Her vitals are WNL. A physical exam is unremarkable with no noted abnormalities. The following questions will be answered as they pertain to the case study patient.
- What other subjective data would you obtain?
The patient stated that she has been having headaches since she was 15, which is 10 years in total, but I would want to know the current onset of symptoms, as she described them as “frequent headaches lately”. I would also want to know the duration of the headaches, the frequency of the headaches, a severity rating of the headaches, triggers of the headaches (e.g., skipping meals, certain odors, excessive caffeine intake, certain foods, weather changes, alcohol consumption, and the onset of menses), any other aggravating factors beyond the photosensitivity (e.g., sensitivity to noise), if she experiences an aura before the headaches (e.g., visual sparkles, flashing lights, visual loss, numbness, or tingling), if she has any drug, OTC, food, or environmental allergies, her vaccination status, how often she is using the ibuprofen and at what dosages, the date of her last menses, and if she is sexually active, trying to get pregnant, or is actually pregnant, which would be very important to know for the safe prescribing of pharmaceuticals, since many medications are teratogenic. Also, she will need to discontinue ibuprofen and switch to acetaminophen should she become pregnant.
- What other objective findings would you look for?
The patient’s vitals are within normal limits and a physical examination shows normal findings. However, I would also auscultate over the carotid and temporal arteries to assess for bruits and palpate the carotids to assess for adequate blood flow to the brain.
- What diagnostic exams do you want to order?
From the included data and symptoms, I’m strongly leaning towards a diagnosis of chronic migraine headache without aura. According to Epocrates+ (n.d.-a), clinical diagnosis for classifying headaches is based on meeting criteria from the International Classification of Headache Disorders, and do not rely on diagnostic testing. The ordering of a CT or an MRI of the head are optional tests, but according to Ruschel & De Jesus (2022), the use of neuroimaging is only indicated for headaches that are acute and very severe, if there is an abnormal neurological exam, the characteristics of the headaches are not typical, there are changes in the patient’s normal patterns, there is resistance to treatment, or there are meningeal symptoms that include fever, weight loss, and fatigue. So far, nothing in the subjective or objective data indicates the need for a CT or MRI of the head, and as a healthcare practitioner I will utilize judiciousness before ordering expensive diagnostic tests that are not necessary. Furthermore, I suspect the patient might be pregnant and not yet aware, as an expected increase in hormones such as progesterone and estrogen, along with the production of hCG, during pregnancy could be the causative reason her migraines are now more frequent. As such, I would order a serum beta-hCG test to confirm or rule out pregnancy, also adding a CMP and CBC with differential for baseline labs in the likelihood she is with child.
- Name 3 differential diagnoses based on this patient presenting symptoms.
The three differential diagnoses I have chosen are chronic migraine headache without aura, chronic migraine headache with aura, and tension headache.
- Give rationales for each differential diagnosis.
The first differential diagnosis chosen is chronic migraine headache without aura. The rationale for choosing this diagnosis is due to the patient’s symptoms occurring for the past 10 years during menses, being unilaterally located, pulsatile, and accompanied by nausea and photophobia, all hallmarks of migraines (Epocrates+, n.d.-b). The inclusion without aura is based on there being no mention by the patient of symptoms of such phenomena. However, further investigation might reveal that symptoms of aura do exist, which would then rule out this diagnosis.
The second differential diagnosis chosen is chronic migraine headache with aura. The rationale for choosing this diagnosis is the exact same for the previously mentioned diagnosis. However, symptoms of aura that precedes the headache or occurs simultaneously would need to be present. These symptoms of aura include visual sparkles, flashing lights, visual loss, numbness, tingling, or dysphasia (Epocrates+, n.d.-c).
The third differential diagnosis chosen is tension headache. The rationale for choosing this diagnosis is because the client has chronic headaches with photophobia and nausea. This diagnosis, though, is more than likely ruled out because a few criteria for tension headache do not match some of the patient’s symptoms. For tension headaches, there is usually bilateral pain that is pressure-like, non-pulsatile, constricting, with photophobia, phonophobia, or mild nausea sometimes experienced (Epocrates+, n.d.-d). In contrast, the patient’s headaches are described as unilateral with pulsations felt.
- What teachings will you provide?
I would educate the patient to take pain relief treatment right away at the first signs of a migraine attack and not to delay, as delaying treatment can result in less effectiveness of the medication and increase the duration of the headache. I would educate the patient to keep a headache diary to help identify triggers and signs that a migraine attack is starting. Depending on what pharmacological treatment will be prescribed (e.g., divalproex sodium [Depakote] or topiramate [Topamax] for migraine prophylaxis), I would educate the client about the risks of serious birth defects associated with taking these medications during pregnancy, and that it is very important that pregnancy tests be routinely done during treatment and that effective contraception needs to be utilized. Lastly, I would educate the patient that over-use of pain medication can result in a medication-overuse headache.
Case study 2: ID
What other subjective data would you obtain?
The subjective data I would obtain is history of present illness, allergies, medications, past medical history, surgical history, review of systems, and immunizations. In this clinical case, beside the information provided in the subjective as part of the interrogatory, I would ask about the onset of the headache (insidious or sudden). I would ask if the patient had previous history of a similar episode. It is important to ask about focalization symptoms (sensitive or motor), associated symptoms as dizziness, visual disturbances as diplopia or visual field defect, numbness or focal muscular weakness, fever or difficulty with speech. About the current medical treatment, I would ask if the patient has been consistent with anticoagulation therapy, and if the blood pressure has been controlled lately. Regarding social history, it is important to assess smoking history, drug use and alcohol consumption. Also, it is important to ask if patient has been taking any OTC medication of supplement that can interfere with medical treatment. As part of the general assessment of this patient, as a physician, it is important to understand why this patient did not seek medical advice or attention. I would educate patient very detailed the possible implications and complications of delayed treatment.
What other objective findings would you look for?
In the abdomen exam, it is important to assess a more thorough neurological physical exam. I would explore deep tendon reflexes (DTRs), detailed and regional muscular strength, and sensitivity and superficial reflexes. Babinski or plantar reflex is very important to determine any anatomical lesion in the pyramidal tract. Also, it is important to perform an eye fundus exam looking for papillary edema or possible retinal bleeding. In the cardiovascular exam, it is essential the auscultation of both carotid arteries looking for bruits.
What diagnostic exams do you want to order?
In this clinical case, it is important to order and EKG, CBC, CMP, PT/INR, PTT, CT brain without contrast to rule out acute intracranial bleeding, Echocardiogram looking for intracardiac embolus, and ultrasound with doppler of bilateral carotid arteries. It is necessary a MRI with contrast or CT Angio of head looking for acute embolization.
Name 3 differential diagnoses based on this patient presenting symptoms.
Transient Ischemic Attack (TIA)
Cardioembolic Stroke
Lacunar Infarct
Give rationales for each differential diagnosis.
Transient Ischemic Attack (TIA): patient had an episode of acute headache with motor focalization affecting her speech, recovered spontaneously. Patient has past medical history of atrial fibrillation and hypertension.
Cardioembolic Stroke: Patient has past medical history of atrial fibrillation and hypertension. Acute presentation of neurological focalization and headache, with sudden onset.
Lacunar Infarct: acute headache with motor focalization affecting her speech, no major motor defect and past medical history of atrial fibrillation
What teachings will you provide?
In this clinical case, it is important to have a discussion with the patient about lifestyle modification and compliance with medical treatment. It is also necessary to assess why she did not seek medical care when she had the acute episode. The timeframe for medical treatment is very important in this case since the delayed medical treatment correspond with more complications and adverse outcome.
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