clinical diagnostic paper
Running Head: Clinical Diagnostic |
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Zandria Hamilton
Migraine
Tyohon ID:1840-20181018-007
12/2/2018
CC:
" I've been having headache for a while" HPI:
Patient is a 29-year-old Caucasian female who reports that she has had a headache for a year. She reports a headache is a constant dull ache located at the back of her neck. She reports the pain is a 6/10 at all times. She states that she has been taking ibuprofen 600 mg three times daily, but the medication provides no relief. She reports that the headache is worst during the day when she is out running every day errands. PMH:
Patient reports no past medical history. Patient reports an MVA that occurred in 2016. Patient reports he sustained no injuries related to MVA. Patient denies having a past surgical history. Allergies:
Reports no known medication, food or latex allergy. Medication:
Patient reports the only medication she is currently on Ibuprofen 600 mg po TID as needed for headache. Social History:
Patient denies recreational drug use. She denies tobacco use. She reports drinking two 8 oz glasses of wine 3 nights weekly. Patient reports she is married with 2 young girls aged 4 and 6. She reports she lives with her husband and 2 daughters. Reports she does not engage in risky sex. Patient reports she is a stay at home mother and is currently unemployed but reports she has a bachelor's degree in Spanish. She states she active member of the Catholic church and attend church every Sunday. Family history:
Patient reports mother is still alive and has a history of hypertension which was diagnosed when she was 45. She states her father has a history of depression, which he was diagnosed with at age 39. Maternal grandmother died at the age of 83, from complications of CHF but medical history is unknown. Maternal grandfather died of complications of Parkinson's at the age of 75, but medical history is unknown. Paternal grandmother is still alive and medical history is unknown. Paternal grandfather is still a live and patient reports she doesn't know his medical history. Patient reports having 2 siblings who don't have any medical conditions. Health maintenance and promotion:
Patient reports she was given a flu shot in December of 2017. She reports that she runs a mile 5 times a week in the morning. She reportedly drinks 84 oz. of water daily. She states that she eats a well-balanced diet. She reportedly eats 5 small meals a day. Based on Recommendations by the USPSTF the patient should be screened for high blood pressure in adults over the age of 18. The recommendation is to obtain measurement outside of the clinical setting for diagnostic confirmation before treating. ROS: General: Patient denies, fever, chills, or malaise. Skin: Patient denies any open wounds, bruises, sores, or any areas of breakdown on skin. HEENT: Patient denies abnormal growths on head. Patient denies having a hard time hearing. He denies ear pain. Patient denies tinnitus. She denies having a sore throat. She denies having nasal congestion. CV: Patient denies having palpations, chest pain, or edema. She reports having hypertension. Lungs: Patient denies having a cough. She denies having shortness of breath. GI: Patient denies being constipated. Patient denies abdominal pain or cramping. She denies and changes in bowel movement. Denies having a decreased appetite. GU: Patient denies any changes to color of urine. She denies having urinary retention. She denies having urgency or frequency. Patient denies having urinary incontinence. PV: Patient denies hyperpigmentation on extremities. Patient denies edema. MSK: Patient denies having trouble ambulating. Patient denies having joint pain. Patient reports having full range of motion in all extremities. Neuro: Patient denies loss of memory. Denies blurred or double vision. Patient denies dizziness. Denies numbness and tingling in extremities. Reports having a localized headache for one year. Patient reports the pain radiates up her head. Reports that pain is constantly a 6/10 on the pain scale. Endo: Denies being intolerant to cold. Denies intolerant to heat. Denies a history of thyroid disease. Psych: Patient denies auditory or visual hallucinations. Denies tactile hallucinations. Denies suicidal or homicidal thoughts. Denies feeling paranoid. OBJECTIVE Gen: Patient is well nourished. She is alert, oriented, calm, and cooperative. She is appropriately dressed for the season. VS: BP=108/62 Pulse= 65 RR= 18 O2=95% Temperature=98.6 degrees fahrenheit Height= 5 ft 22 inches Weight = 127lbs BMI= 23.2 (Normal) SKIN: Upon inspection skin is intact with no obvious open wounds or bruises noted. Upon palpation skin the skin is warm and dry. Skin is thin and fragile. HEENT: Inspection of the head reveals head is norm cephalic. Hair is thick and evenly distributed across head. No deviated septum noted. PERRLA. CV: Heart S1 and S2 noted, RRR, no murmurs or additional sounds noted. Lungs: Lungs auscultated breath sounds present and clear in all lobes. No wheezing, rhonchi, or stridor noted. ABD: No abdominal tenderness noted upon palpation. Bowel sounds present in all quadrants on auscultation. GU: Deferred PV: No hyperpigmentation noted in extremities. No edema noted. MSK: Patient has full range of movement in all extremities. Neuro: Gait is steady. CN II-XI grossly intact, no ataxia noted. Strength is equal in upper and lower bilateral extremities. No signs of weakness noted. Speech is clear. She is alert and oriented. Memory is intact. Psych: No delusions noted. No self-conversing noted. Mood is appropriate. Behavior is appropriate. Thoughts are organized and clear. Diagnostics
CT scan of the head (Ferri, 2015)
Lumbar puncture (Ferri, 2015)
Assessment
1) G43.0 Migraine without aura (common migraine).
Therapeutics:
Propranolol 80 mg/day PO divided q6-8hr initially; may be increased by 20-40 mg/day every 3-4 weeks; not to exceed 160-240 mg/day divided q6-8hr. Education:
Educate patient on the importance of early administration of medication (Ferri, 2015).
Educate patient on the importance of Avoiding any identifiable provoking factors: caffeine, tobacco, and alcohol may trigger attacks, as may dietary or other environmental precipitants (Ferri, 2015)
Encourage patient to avoid stressors in life and minimize variations in daily routine with regular sleep, meals, and exercise (Ferri, 2015). Referral: To neurologist if uncertain about diagnosis or treatment not effective (Ferri, 2015).
Clinical Decision Making
Pathophysiology- Although, the exact pathophysiology of migraines is on clear it is suggested that the characteristic pathophysiology of a migraine starts in the cortical spreading depression of neural impulses from a focal point of vasoconstriction which is followed by vasodilation (Reddy, 2013). In those who suffer from migraines the spreading depression passing through nerve cells stimulates the release of many endogenous substances which result in inflammation this then make the nerve fibers more sensitive to pain and causes vasodilation (Reddy, 2013).
Pharmacology information- Propranolol 80 mg/day PO divided q6-8hr initially; may be increased by 20-40 mg/day every 3-4 weeks; not to exceed 160-240 mg/day divided q6-8hr. Propranolol is classified as a beta-1 blockers drug (Bulboacă, Bolboacă, Stănescu, Sfrângeu, & Bulboacă, 2017). A hyperexcitable brain state which is based on cortical spreading depression (CSD) has been postulated as a pathophysiological mechanism in migraine. Normalizing neuronal firing and altering the threshold for neuronal discharge, based on modulation of CSD, are an important therapeutic target in migraine. Studies have shown that Propranolol inhibit the CSD in rats (Bulboacă, Bolboacă, Stănescu, Sfrângeu, & Bulboacă, 2017). About 84-92% of an oral dose Propranolol is excreted in the 48-hour urine. Propranolol's brand name is Inderal. The average retail price of Propranolol is 30 dollars for a 30-day month supply. This medication was chosen because beta blockers are typically first line of choice when dealing with prophylactic therapy for migraines. Propranolol has the best level of evidence and fewer side-effect (Ferri, 2015).
Critical Thinking / Clinical Decision Making-
Cerebral neoplasm is should be considered a differential diagnosis because migraines are a common symptom in patients who have cerebral neoplasms however a patient with migraines that commonly occur with neoplasms are progressive in pattern and neurological signs or symptoms typically occur in conjunction (Ferri, 2015). This patient complains of a constant headache. CT or MRI scans will help to rule out possible cerebral neoplasm.
Subarachnoid hemorrhage (SAH)- is also be considered as a differential diagnosis because migraines are a common finding in SAH however the migraine that occurs with a SAH is often severe and has a sudden onset and the patient has had the headache a year (Ferri, 2015) . SAH can be ruled out by a CT scan if CT is negative a lumbar puncture may be necessary. Angiography may be considered.
Ethical and or Cultural Concerns-
No ethical or cultural concerns were noted.
Barriers to Care-
Potential barriers to care include inability to recognize the importance of self-care. As a mother with small children her focus is ensuring that they are cared for adequately which may result in her health being placed secondary to everything else in life. While attempting to schedule her CT scan the patient could only focus on ensuring that the scan would not conflict with her children's schedule. She stated that any doctor's appointment must be schedule around them. Understanding her concerns and making accommodations to adjust to the children's schedule will ensure that she continues to follow up with treatment plans. However not accommodating the children's schedule may lead to non-compliance with treatment.
Evidence based practice-
When is the appropriate time to start daily preventative therapy for migraines and what medications are the most effective? According to American Migraine Prevalence and Prevention Study, the best time to start preventative therapy is when a patient has at least 6 headaches a month or at least 4 days a month with some impairment or at least 3 days month with severe impairment or requiring bedrest (Estemalik & Tepper, 2013). Propranolol and metoprolol have the best evidence in migraine prophylaxis. Several trials show clear and consistent evidence that propranolol is more effective than placebo, although the majority of these have methodological weaknesses. Its efficacy is nonetheless considered to be well established and has been supported by a Cochrane review (Rubesh , Randa , and Fayyaz, 2013). According to several studies the patient should be started on a beta blocker due to the chronic nature of her headache.
Self- Reflection-
Going forward and knowing migraines typically runs in families I would be sure to ask the patient about family history in relation to her migraines and if there was a family, I’d inquire about what medications were successful in treating migraines in family members. Often migraines aren't mentioned in family history. After looking back over what I could have done differently during this patient encounter. I would have stressed to the patient the importance of self-care and self-preservation. My concerns are that this patient doesn’t recognize when she needs to care for herself. Perhaps providing her with a plan to ensure that her children are adequately cared for while she receives the care that she needs. As a single mother I know first-hand how difficult it is to decide to care for yourself. Encouraging the patient to be an advocate for herself is very important.
Reference
Bulboacă, A. E., Bolboacă, S. D., Stănescu, I. C., Sfrângeu, C. A., & Bulboacă, A. C. (2017). Preemptive analgesic and antioxidative effect of curcumin for experimental migraine. BioMed Research International, 2017, 7. doi:http://dx.doi.org.prx-herzing.lirn.net/10.1155/2017/4754701
Estemalik, E., & Tepper, S. (2013). Preventive treatment in migraine and the new US guidelines. Neuropsychiatric disease and treatment, 9, 709-20.
Ferri, F. (2015). Ferri's Clinical Advisor 2016. Migraines. Elsevier Health Sciences.
Reddy, D. S. (2013). The pathophysiological and pharmacological basis of current drug treatment of migraine headache. Expert Review of Clinical Pharmacology, 6(3), 271-88. doi:http://dx.doi.org.prx-herzing.lirn.net/10.1586/ecp.13.14
Rubesh, G., Randa N., and Fayyaz, A. (2013). Evidence-Based Treatments for Adults with Migraine. Pain Research and Treatment, 2015, 13. https://doi.org/10.1155/2015/629382
U.S. Preventive Services Task Force (April 2014). USPSTF A and B Recommendations: Blood pressure screening: adults. Retrieved from U.S. Preventive Services Task Force: https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations
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