HA9

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Case: 2 “Intermittent headaches” Scenario. 3 “A 20-year-old male complains of experiencing intermittent headaches. 4 The headaches diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw.” Patient: M. I. Age: 20, Sex: Male Race: Caucasian SUBJECTIVE:

CC: 2 “intermittent headaches” HPI: At 11 A.M, a 20-year-old Caucasian male visited the clinic with complaints of intermittent headaches spread across the head intracranial regions. 5 He reported that the pain spreads to the jaw, cheekbones, nose, and above the eyes when the neck and scalp muscles tense.

Location: Generalized headache

Onset: intermittent for two months.

Character: Pressure

3 Associated signs and symptoms: 6 phonophobia, photophobia, nausea.

Timing: Intermittent but mostly in the evening after work

7 Exacerbating/ relieving factors: noise, light

Severity: 8 7/10 pain scale.

Current Medications: OTC Acetaminophen mg PO every 6 hours for pain.

Allergies: rash, strawberries, latex.

PMHx: 9 No significant known medical history. 10 He was given the last tetanus shot in May 2018. 11 Other immunizations shots are up to date.

Soc Hx: Denies alcohol intake. Denies smoking or being exposed to secondhand smoke. He is a college-going young adult active in soccer sports. Heterosexual and single. He reports to lack of interest in dating but concentrates on education. He lives with his parents. 11 Every time he is in a motor vehicle, he wears his seat belt. He does not use a cellphone while driving. He takes about 1-2 liters of caffeinated drinks.

Family Hx: both parents are alive with 2 siblings. Father is 81, living with diabetes. Mother is 70 managing HTN. His siblings are schooling with no history of medical conditions. 3 His grandparents are deceased due to natural causes.

ROS:

GENERAL: 12 denies any fevers, night sweats, weight loss and chills.

HEENT: Eyes denies blurred vision, watery eyes, visual loss, wearing glass though states eyes are extremely sensitive to light which triggers the headache. Ears: 6 denies discharge, pain, hearing problems. Nose: reports to experience pain around the sinus area and seasonal rhinorrhea. Throat: 6 denies difficulty swallowing, speaking, pain.

SKIN: denies any lesion, bruising, itching, or burning

CARDIOVASCULAR: denies edema, palpations. 11 Denies chest pressure, chest pain or discomfort.

RESPIRATORY: 6 denies cough, breathing difficulty.

GASTROINTESTINAL: 13 reports nausea, vomiting and anorexia with headaches.

GENITOURINARY: 4 denies burning on urination.

NEUROLOGICAL: 6 denies bladder control or bowel changes. Denies ataxia, syncope, numbness, dizziness, stiffness, or joint pain.

MUSCULOSKELETAL: 14 denies joint/muscle pain. reports pain in the forehead. Denies back pain.

LYMPHATICS: 11 denies enlarged nodes.

PSYCHIATRIC: denies anxiety. Reports to seek any treatment in the past.

ENDOCRINOLOGIC: denies frequent urination, excess hunger, and thirst.

ALLERGIES: latex produce rash response. 2 No history of eczema, asthma, hives, or rhinitis. 3 Seasonal sneezing and allergies with rhinorrhea.

OBJECTIVE.

Vital Signs: 15 Height is 5’10”, Weight is 146 pounds; HR: 72, RR: 18, Temp: 97.5, BP: 15 123/64, Spo2 100% on Room Air.

Physical exam:

General: 15 Well, appearing, well-groomed and well-nourished male in no obvious signs of distress: Skin: 16 Skin is warm and dry, no diaphoresis

HEENT: 3 HEENT are normal appearing, no rhinorrhea, hearing loss, or swallowing difficulties

Cardiovascular: 15 normal S1, S2 heart sounds, regular rate, no chest pain; 3 no rubs, gallops or murmurs.

Respiratory: 15 Lungs are clear to auscultation; respiratory rate is regular.

Gastrointestinal: 3 No abdominal pain or tenderness. 15 + Bowel sounds in all 4 quadrants. Last BM: 3 1/23/18

Genitourinary: 3 No difficulty voiding

Neurological: 3 Alert and oriented, no headache presents at time of examination

Musculoskeletal: 15 range of motion in all joints are normal, no signs of weakness, equal strength in all 4 extremities.

Hematological: 17 no signs of bruising or petechiae Lymphatic: 3 lymph nodes are non-edematous and non-tender

Psychiatric: 17 Patient exhibits no signs of depression or anxiety Endocrinologic: 3 No seasonal allergies or rhinorrhea

Diagnostic results:

14 CBC (Complete Blood Count) – Ordered to detect any abnormal lab findings

18 CT scan – pending findings should be completed in the presence of abdominal, neurological data or with a new-onset headache to detect the presence of intracranial disease (Kim et al., 2017).

Erythrocyte Sedimentation Rate – the diagnostic test is used if the client is suspected of having arthritis in the presence of elevated inflammation (Dains, Baumann & Scheibel, 2017).

Skull Radiography- helps providers to view intracranial structures when examining post-trauma (Smith, 2021).

Differential Diagnoses

Tension-type headache – based on the presenting, this disease is the presumed diagnosis because it is causing a gradual pain when the scalp muscles and the neck tense to produce mild to intense pain behind the eyes, head, and neck (Smith, 2021). The muscles could be contracting due to stress and may last a day or a few hours.

Brain Tumor- is another diagnosis because headaches depend on where they are in the brain. The pain occurs intermittently, starting gradually due to accumulated pressure in the intracranial region, obstructing the cerebral spinal fluid flow (Kim et al., 2017).

Bacterial Meningitis- this type of headache pain may come and go. The patient’s complaint of pain may be due to Cryptococcus neoformans that begin gradually and subtly (Ball et al., 2017).

Sinusitis- when the patient forward, the headache pains may be associated with a diagnosis of sinusitis. The symptoms of this diagnosis are migraine, facial pain, and

2 headache over the sinuses (Kim et al., 2017).

Carbon Monoxide Poisoning- this diagnosis because, as discussed in tension-type headaches, the patient may be experiencing dizziness and pain due to poisoning of the carbon monoxide, which causes severe headaches, fatigue, and dimmed vision (Dains, Baumann & Scheibel, 2017). Poisonous carbon monoxide gas binds with hemoglobin in the blood interfering with oxygen circulation.

Plan.

Acetaminophen 1000 mg BID every 6 hours as needed.

Plenty of rest (8-10 hours of sleep a day).

Drink lots of fluid, especially water (6-8 glasses of water a day).

19 References Ball, J. 20 W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2017). 8 Seidel's Guide to Physical Examination-E-Book: An Interprofessional Approach. 21 Elsevier Health Sciences.

Dains, J. 2 E., Baumann, L. C., & Scheibel, P. (2017). 1 Advanced Health Assessment & Clinical Diagnosis in Primary Care-E-Book. 21 Elsevier Health Sciences.

2 Kim, J., Cho, S. J., Kim, W. J., Yang, K. 18 I., Yun, C. H., & Chu, M. K. (2017). 2 Insomnia in tension-type headache: a population-based study. The journal of headache and pain, 18(1), 1-9.

Smith, J. H. (2021). Other Primary Headache Disorders. CONTINUUM: Lifelong Learning in Neurology, 27(3), 652-664.