Case Study: Headaches Essay Assignment

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Case Study: Headaches Essay Assignment

Patient Information:

Initials J.M

Age: 20 years old

Sex: Male

Race: African American

S.

CC: J.M. is experiencing intermittent headaches.

HPI: A 20-year-old African American man complains of intermittent headaches over the past three weeks. The headache diffuses throughout the head, with the most intense sensations felt around the cheekbones, nose, jaw, and above the eyes. Initially dull, the pain intensifies to an aching or throbbing sensation. The patient attributes the headaches to recent stress from his college and job. The headaches happen at different times of the day and are reported to be relieved to some extent by Ibuprofen, though the pain reaches a peak intensity of 6/10 on the pain scale. Case Study: Headaches Essay Assignment

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Current Medications: The patient takes Ibuprofen 400 mg PO Q for pain.

Allergies: J.M. reports NKDA

PMHx: His immunizations are up to date. Last Tetanus shot was7/2022.

Soc Hx: J.M. is currently a part-time college student majoring in engineering. He also works part-time at a local grocery store to support his education financially. In his leisure time, John enjoys playing basketball with friends and spending time with his family.

Fam Hx: J. M’s family history reveals no significant medical conditions reported by his parents or younger sister. On the paternal side, his grandfather died from a heart attack at 72, and his grandmother’s cause of death is unknown. On the maternal side, his grandfather is living with type 2 diabetes and hypertension. His grandmother passed away at 65 following complications from a stroke.

ROS:

GENERAL: The patient appears a well-developed, well-nourished 20-year-old African American male in no acute distress.

SKIN: No rashes, lesions, or changes in skin texture reported.

HEAD: Intermittent headaches present for the past 3 weeks, diffuse throughout the head with the most intense sensations felt around the cheekbones, nose, jaw, and above the eyes. Pain described as initially dull and progressing to an aching sensation. Peak pain intensity reported at 6/10 on the pain scale. Case Study: Headaches Essay Assignment

EYES: No double vision, visual changes, discharge, or eye redness.

EARS: No hearing loss, ear pain, or tinnitus.

NOSE: No nasal discharge, or nasal congestion.

MOUTH/THROAT: No sore throat, no difficulty swallowing, no dental issues reported.

RESPIRATORY: No wheezing, shortness of breath, or cough.

CARDIOVASCULAR: No palpitations, chest pain, or edema reported.

GASTROINTESTINAL: No alterations in bowel movements, nausea, abdominal pain, or vomiting.

GENITOURINARY: No urinary frequency, no urgency, no pain or discomfort during urination.

MUSCULOSKELETAL: No muscle weakness or stiffness.

NEUROLOGICAL: No numbness, tingling, or weakness reported in the extremities.

PSYCHIATRIC: Patient attributes headaches to recent stress from job and college, denies any history of depression or anxiety.

ENDOCRINE: No excessive thirst, no excessive hunger, no changes in weight. Case Study: Headaches Essay Assignment

HEMATOLOGIC: No history of bleeding disorders or easy bruising.

ALLERGIC/IMMUNOLOGIC: Patient denies any known drug allergies.

O.

Vital Signs: BP: 120/80 mmHg, HR: 70 bpm, RR: 17 breaths/min, Temp: 98.5°F (37°C), SpO2: 98% (room air), Weight: 70 kg, Height: 175 cm.

Physical Exam:

General: The patient appears a well-developed, well-nourished 20-year-old African American male in no acute distress.

Head: Atraumatic and normocephalic. No signs of tenderness or deformities observed.

Eyes: Equal pupils, round, and reactive to light. No conjunctival redness or discharge noted. Visual acuity is intact, and no visual disturbances reported.

Ears: Bilateral tympanic membranes are pearly gray and intact. No signs of inflammation or discharge observed.

Nose: Nasal mucosa appears pink and moist. No nasal congestion or discharge noticed.

Throat: Oropharynx is clear without redness or tonsillar enlargement. No signs of tonsillar exudates or ulcers.

Neck: Neck is supple without lymphadenopathy. Range of motion is unrestricted, and no signs of neck stiffness. Case Study: Headaches Essay Assignment

Cardiovascular: Heart sounds are normal.

Respiratory: Lung fields are clear to auscultation bilaterally.

Abdomen: Abdomen is non-distended, soft, and non-tender. Bowel sounds are present in all quadrants. No organomegaly or masses palpable.

Musculoskeletal: No joint swelling or deformities. Full range of motion in all extremities without pain or limitation.

Skin: Skin is warm and dry with no rashes or lesions observed. No signs of inflammation or infection.

Patient History Collection:

The necessary history to collect from the patient in the assigned case study includes;

  1. Details concerning the characteristics of intermittent headaches, such as frequency, duration, and associated symptoms.
  2. The patient’s stress levels, coping mechanisms, and stress intensity or frequency changes should be assessed.
  • A comprehensive medication history, including the use of Ibuprofen, is crucial.
  1. Evaluating the patient’s sleep patterns and habits will provide essential insights. Case Study: Headaches Essay Assignment

Physical Exams and Diagnostic Tests:

  1. Neurological Examination:To assess cranial nerve function, motor strength, sensation, reflexes, and coordination to identify any neurological issues contributing to the headaches (Hussain & Fadel, 2020).
  2. Blood Pressure Measurement:To screen for hypertension, considering the family history of cardiovascular issues, as uncontrolled high blood pressure can trigger headaches (Hussain & Fadel, 2020).
  3. Blood Tests (CBC and CMP):To rule out systemic abnormalities, infections, or underlying medical conditions that could be related to headaches.
  4. Eye Examination:To evaluate for any signs of inflammation or visual changes contributing to the headaches (Hussain & Fadel, 2020). Case Study: Headaches Essay Assignment

Diagnostic Test Results:

The results of these exams and tests will aid in identifying any potential neurological abnormalities, hypertension, systemic abnormalities, or underlying medical conditions that could be causing the headaches. Based on the findings, the medical professional can rule out or confirm specific conditions, leading to an accurate diagnosis. The data gathered will guide the development of an appropriate treatment plan tailored to address the root cause of the headaches and relieve the patient’s symptoms. Case Study: Headaches Essay Assignment

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Differential Diagnosis:

  1. M’s intermittent headaches present a broad range of possible conditions. A comprehensive differential diagnosis is imperative for accurate diagnosis and effective treatment. The potential conditions to consider are:
  2. Tension-type Headache: According to Steel et al. (2021), tension-type headaches are usually triggered by anxiety, stress, or tension in the muscles of the neck and head. The patient’s reported stress from his job and college studies aligns with this headache. The characteristic pressing or tightening sensation on both sides of the head is consistent with tension-type headaches.
  3. Migraine Headache: Migraine headaches are known for their severe intensity. They can be associated symptoms like vomiting, nausea, light sensitivity, and visual disturbances (aura). While the patient does not report experiencing aura, nausea, and light sensitivity can still indicate migraine headaches (Ha & Gonzalez, 2019).
  4. Sinusitis: Inflammation of the sinuses can lead to facial pain and headaches, particularly when bending forward or lying down. The patient’s description of pain around the cheekbones, jaw, and nose could be associated with sinusitis (Psillas et al., 2021). Case Study: Headaches Essay Assignment
  5. Cluster Headache: The intense, one-sided headaches that occur in clusters over a while, often accompanied by nasal congestion and eye redness, match the characteristics of cluster headaches. According to Brandt et al. (2020), exploring the presence of these additional symptoms during the patient’s history is essential to confirm this diagnosis.
  6. Cervicogenic Headache: Headaches originating from the neck or cervical spine, frequently due to poor posture or neck injuries, could be considered. The patient’s reported pain in the jaw and cheekbones may indicate cervicogenic headaches if it is related to cervical spine issues (Barmherzig & Kingston, 2019). Case Study: Headaches Essay Assignment

References

Barmherzig, R., & Kingston, W. (2019). Occipital neuralgia and cervicogenic headache: diagnosis and management. Current neurology and neuroscience reports, 19, 1-8.

Brandt, R. B., Doesborg, P. G., Haan, J., Ferrari, M. D., & Fronczek, R. (2020). Pharmacotherapy for cluster headache. CNS drugs, 34, 171-184.

Ha, H., & Gonzalez, A. (2019). Migraine headache prophylaxis. American family physician, 99(1), 17-24.

Hussain, H., & Fadel, A. (2020). Malignant Hypertension Without End-Organ Damage Secondary to Stressful Condition in a Female. Cureus, 12(8).

Psillas, G., Papaioannou, D., Petsali, S., Dimas, G. G., & Constantinidis, J. (2021). Odontogenic maxillary sinusitis: A comprehensive review. Journal of dental sciences, 16(1), 474-481.

Steel, S. J., Robertson, C. E., & Whealy, M. A. (2021). Current understanding of the pathophysiology and approach to tension-type headache. Current Neurology and Neuroscience Reports, 21, 1-12. Case Study: Headaches Essay Assignment