APA format 3 peer references and response needs to agree or disagree with differential diagnosis and explain why
Week 9: Review of case study 1
Patient Initials: _AS__ Age: __20___ Gender: __M_
SUBJECTIVE DATA:
Chief Complaint (CC): an Unbearable headache
History of Present Illness (HPI): 20-year-old Caucasian male presented with a chief complaint of intermittent headaches. The patient reports that a headache is so bad and unrelenting that he feels it in his eyes with great intensity, nose, cheekbones, and jaw. The patient states “The headache ache comes and goes.” The patient reported that his headache started two days ago and had increased in severity of a 10/10 on the pain scale as the pressure in the eyes creating the sensitivity to light, the feeling of having toothache makes it too hard to bear. While the patient was not able to pinpoint when his headache started, he reports that he was so overwhelmed with school and work over the past couple of weeks, it may have precipitated the headache. The patient reporting taking Tylenol which is ineffective; he has tried to get more sleep and use dimmed lights while awake. He states, “while the sleeping for a longer time helps a little, the headaches return as the day progress and gradually gets worse with each passing minute. The only thing that stops the headache is passing time.”.
Medications: Tylenol 650 mg every 4 to 6 hours.
Allergies: Ibuprofen- angioedema
Past Medical History (PMH): Mumps -resolved
Past Surgical History (PSH): Appendectomy at age 16 due to a ruptured appendix.
Sexual/Reproductive History: Not sexually active.
Personal/Social History: Reports going to church on Saturdays (worship sunset to sunset), Saturday after sabbath worship; sometimes going bowling or roller skating and socializes with peers from church or school. Denies tobacco use, alcohol use, and drug use. Patient reports at least three mornings per week approximately one hour of exercise at the work gym.
Immunization History: reports immunization up to date and will get his annual flu shot at work October 25, 2018.
Significant Family History: grandfather died one year ago (72) from heart failure. Grandmother 68 alive and living with hypertension.
Lifestyle: Patient is newly as a mental health counselor at a hospital psychiatric unit. He just started studying law part-time at the local university; current course is online. He currently lives alone in a two-bedroom apartment, as parents live in another country. His support system is his family who is a phone call away, and his best friend who lives 20 minutes away from his home. He does not drink, smoke or do drugs. He attends church on Saturday. Socializes with church friends and or best friend after sunset some Saturday at the local bowling alley, skating rink, or “hang out” at a local diner. Currently is not involved in a relationship and is not sexually active.
Review of Systems:
General: Patient reports having an “unbearable headache” Patient is unaware of any changes in weight, eating preference or activities; however, reports a decrease in appetite.
HEENT: “except for the increasing headache no problem.”, reports wearing shades due to an increased sensitivity to lights; no hearing impairment; reports stuffy nose in the morning in the morning but no runny nose; denies difficulty chewing or swallowing, pain or discomfort.
Neck: Endorses stiffness, reports “may be due to tension.”
Respiratory: denies any respiratory distress
Cardiovascular: denies palpitation, denies heart problems
Gastrointestinal: Reports decreased appetite, some nausea, no vomiting no change in bowel pattern noted.
Genitourinary: No change in urinary function
Musculoskeletal: Denies problem with range of motion, walking or gait.
Psychiatric: Denies having any psychiatric history
Neurological: Reports feeling less alert, unfocused at times.
Skin: Denies any dermatological problems
OBJECTIVE DATA:
Physical Exam:
Vital signs: temp: 98.4, b/p 130/74, RR 18, pulse 88, SPO2 100% ht. 5’7” weight 140 BMI 21.9.
General: Patient is an alert and oriented *4, 20-year-old Caucasian male who appears to be in good health. He is appropriately groomed, no odor and looks clean. Erect posture, steady gait. Facial expression looks strained and sad; mood appears dysphoric. He is speaking English fluently and clearly. Voice is low and calm. Speech appear slowed and forced. The patient was able to count from 1-20 backward and repeat a series of words without hesitation. Reports having a headache for a long time, “maybe age 11, really not sure, but they weren’t this awful or frequent.”. For the past four months he has been having headaches for at least four days straight per month; but, this latest bout of headaches has been the worst experienced. He denies any head injury or trauma, and chronic illnesses. Patient report at its worst the pain is 10/10, and at its best, it is 7/10. He also states, “while I take Tylenol, I don’t think it effective; I think time passing makes it goes away, the problem is times seem to go too slow.”.
HEENT: head is symmetrical and normocephalic, no depression, swelling but reported tenderness. Denies head injury or trauma. No facial drooping, Patient endorses headache that is currently a 7/10. Reports pain is to present at forehead bilateral, temporal artery has no bruit, patient reports feeling like a “pressured weight” on his head. Patient does report some pulsating pain with movement. He also endorses feeling the pain behind the eyes, nose, cheekbones and jaw. His forehead is creased. Eyes are symmetrical. Left eye appears glossy, no crusting, no nicking of arteries, optic disc is reddish orange, no microaneurysm, neovascularization. Patient states, “pain can be felt in the eyes and vision in the left eyes sometimes vision seems blurred or doubled and funny”. On evaluation the patient can read clearly at 20/20 on the Snellen eye chart. Pupils are equal, rounded, reactive to light and accommodation. Peripheral vision is intact. No excess blinking, denies pain on examination. No wax in the ear, symmetrical, clean, no difficulty hearing bilaterally during whisper, Weber and Rinne test, no infection or lesion noted, the handle of malleus, light reflex, and the umbo is visualized as the membrane is pearly gray. Nose is midline, no stuffiness, no redness, no drainage noted. Lips are pink and moist, no cavities noted, reports last dental exam and cleaning was September 2018. Tongue is light pink and moist, no problem with swallowing, hard and soft palate gag reflex. Tongue is flexible and resistant to force. Salivary glands are functional. No pain reported on examination.
Neck: Good range of motion, lymph nodes are not palpable; however, tension can be felt in the neck, appears as if the patient has difficulty relaxing. The trachea is midline; thyroid is non-palpable.
Chest: No wheezing, rhonchi, or rales
Lungs: clear in all four quadrants
Heart: no murmurs or abnormal heart sound
Abdomen: flat and no tender, bowel sounds present in all four quadrants, no reports of difficulty in bowel movement or change in the pattern
Musculoskeletal: range of motion is good, no curvature noted. No swelling, redness or tenderness. Some stiffness in the neck but not related to the range of motion but to the patient not being able to relax/ patient is tense. No difficulty in standing, walking in a straight line, stopping or turning suddenly. Balance and gait are exceptional. Patient report having frequent muscle contraction.
Psychiatric: While presently dysphoric, no indication of depression on assessment, the patient appears future-oriented. Denies suicidal and homicidal ideation as well as auditory and visual hallucination. Headache complaint does not appear somatic.
Neurological: Cranial nerve assessment finds all nerve intact with no impairment. The patient is alert and oriented to person, place, time and situation. He can do serial addition and multiplication; repeat a series of words after having a different line of conversation. Count from 1-20 backward. No numbness or tingling in fingers, toes, or face. Muscle strength is (5) good as there is active motion against full resistance, reflex is 2+ normal. Patient can recognize writing on skin, interpret hard and soft with eyes closed. While no sensory issue is present patient reports based on the increased level of activity on the unit at the increase stimuli has been affecting his concentration; he feels overstimulated believes he cannot process new information right now, only wanting to concentrate on one task at a time. He also reiterates that bright light bothers his eyes and the combination with the increased stimulants makes the headache worst. Patient reports feeling less alert and unfocused; however, while this may occur, this neurological exam does not correlate.
24 Hour diet and activity recall: – woke 5:30 or work 8-hour work day which begins at 7 am. 10 am, Breakfast 2 boiled eggs, a slice of toast with a slice of cheese, a bowl of cereal and a glass of coffee. Lunch, chicken Caesar salad. No dinner, went straight at 4pm home after work headache was too intense. Slept for 3 hours, headache was still present but less intense, spent 4 hours on school work then went back to sleep, slept until 5:30 am, then got ready for work. Reports drinking on average four to five glasses of water per day. Patient does not cook, will sometimes eat frozen tv dinners or ramen noodles; sometimes snacks heavily, his favorite snacks are chocolate ice-cream, eclairs, Cheetos and Doritos.
Diagnostic test MRI, and or CT-scan, and complete blood count to rule out inflammation.
ASSESSMENT:
Tension Headache- Per Dains, Baumann & Scheibel, (2016) Tension headache is the most common type of headache in adults, and the pain is bilateral, and last for hours to days, and it can form a cycle that may last for months. The text also notes that factors such as stress, hunger and depression can trigger this headache. Based on information gained from AS, stress is likely a contributing factor to AS headaches. However, results from imaging and testing are needed to determine his type of headache. In a randomized clinical study conducted by Omidi, & Zargar, (2015) they found that the use of psychotherapy dubbed mindfulness-based stress reduction was helpful in reducing pain and stress and would be a useful tool in relieving the tension headache.
Migraine- Per Dains, Baumann & Scheibel, (2016) migraine without aura is seen in 20% of the population, has a unilateral throbbing pain with symptoms of nausea and photophobia. According to Tai, Yap, & Goh, (2018) dietary intake can trigger migraine headaches. They conducted a study that found that coffee, chocolate and monosodium rich foods such as broth, flavored snacks, frozen foods, and pasta sauce can trigger a migraine. It is clear from AS description he is experiencing throbbing pain and is experiencing nausea and photophobia, however, he does states that his headache is bilateral. Hence a leaning towards mixed headache diagnosis. However, this differential diagnosis cannot be ruled out as the patient may also have a migraine with aura as well. In any event, diet change and food choices must be discussed with the patient has some of AS choices is likely a trigger to his headache.
Mixed headache- According to Dains, Baumann, & Scheibel, (2016) is a combination of tension and migraine whereby the effect is a combination of throbbing, tightness, pressure and constant pain is felt. Based on AS description this may be what he is experiencing, therefore, this is an important differential diagnosis Krøll, Hammarlund, Westergaard, Nielsen, Sloth, Jensen, & Gard, (2017) performed a study on mixed headaches; the writers noted that while this type of headache is common, very little study is done, so there are not many tailored interventions exist to help the patient. Therefore, more studies are needed to help understand mixed headaches and proper medication modalities, and alternative remedies, to help alleviate and manage the pain.
Conclusion
Per Dain, Baumann, & Scheibel, “headache and nausea are associated with head trauma, stroke, and tumor.” While this may true in many cases, headaches do not seem to have a definitive cause and appear to be puzzling as some headaches have no underlying factors and give no warning. As always pain is what the patient says, so determinants are based mostly on the information provided by the patient. Therefore, asking the right questions is very important. Diagnostic tests, lab test, and physical assessment is done to ensure patient body systems; neurological functionalities are not affected as headaches could be secondary, as a result of many other medical issues; such as sinusitis, meningitis, optic neuritis, or a tumor.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Krøll, L. S., Hammarlund, C. S., Westergaard, M. L., Nielsen, T., Sloth, L. B., Jensen, R. H., & Gard, G. (2017). Level of physical activity, well-being, stress and self-rated health in persons with migraine and co-existing tension-type headache and neck pain. The Journal of Headache and Pain, 18(1), 46.
Omidi, A., & Zargar, F. (2015). Effects of mindfulness-based stress reduction on perceived stress and psychological health in patients with tension headache. Journal of Research in Medical Sciences, 20(11), 1058–1063
Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.
Tai MLS, Yap JF, & Goh CB. (2018). Dietary trigger factors of migraine and tension-type headache in a South East Asian country. Journal of Pain Research, Vol Volume 11, Pp 1255-1261 (2018), 1255
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