Kathleen Parks iHuman More Frequent Severe Headaches
Reason for encounter
More frequent severe headaches
History of present illness (HPI)
A 26-year old female; Kathleen Parks presents in the outpatient clinic for evaluation of a 10-year history of headaches that have recently become more frequent and intense, are preceded by blurred vision, with severe incapacitation. The headaches are localized behind her left eye, denies radiation. In the past 10 years, the headaches have been happening every 1-2 months but recently, they occur every 1-2 weeks. Potential triggers that she has identified include; work and school-related stress, red wine, and junk food. She has taken acetaminophen & ibuprofen which initially worked but can no longer help. When least severe, she rates intensity as 2 or 3 out of 10 and when most severe, severity is 8 or 10 out of 10. She also reports associated photophobia, phonophobia, nausea & vomiting. She denies tingling/numbness, confusion, fainting, dizziness, neck pain.
Problem Statement
Kathleen Parks is a 26-year old female presenting today in the outpatient clinic for evaluation of longstanding headaches that he persisted for the last 10 years and are now increasing in intensity and frequency. Episodes occur every 1-2 weeks each lasting up to 15 hours and associated with photophobia, nausea & vomiting, and phonophobia. Social history is significant for consumption of red wine, chocolates, junk food, school and wok-related stress. Physical exam is unremarkable.
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Management Plan
Diagnostic tests
- No additional diagnostic tests are needed in this visit
Medications: type a specific prescription for each medication, including over-the-counter medications
- Metoclopramide 10mg by mouth 6-8 hourly for the nausea & vomiting
- Naproxen 500mg stat
- Sumatriptan 50mg stat and repeat in 2 hours if necessary. Do not exceed 200mg in 24 hours (Ashina et al., 2021).
Suggested consults/referrals
- Neurology consult for further evaluation and management (Ashina et al., 2021).
Client education
- Educate patient the warning symptoms to watch out for such as; neck pain, neck stiffness, fevers, progressively worsening headaches
- Educate patient of supportive treatment options to be part o such as; avoiding screen time 2 hours before bed, having atleast 8 hours of sleep every day, decreasing the intake of caffeinated beverages, identifying and avoiding triggers (chocolates, red wine, and junk food), and embracing healthier stress reduction strategies such as daily physical activity (Ashina et al., 2021).
- Educate patient about migraines, risk factors, signs & symptoms, treatment, side-effects, and warning signs/symptoms to prompt emergency care.
- Encourage medication compliance with close follow-up to evaluate for progress
- Encourage close monitoring with a headache diary that improves understanding of potential triggers, and patterns (Ashina et al., 2021).
Follow-up, including time interval and specific symptomatology to prompt a sooner return.
- Follow-up with this clinic in 6-8 weeks to evaluate for response with medications and make necessary adjustments
- Seek emergency care if you develop fevers, worsening headache, neck stiffness, nausea & vomiting, or neck pain (Ashina et al., 2021).
- Follow up with this clinic if you experience changes such as worsening headaches, increased intensity, continuous worsening
Reference
Ashina, M., Buse, D. C., Ashina, H., Pozo-Rosich, P., Peres, M. F., Lee, M. J., & Dodick, D. W. (2021). Migraine: integrated approaches to clinical management and emerging treatments. The Lancet, 397(10283), 1505-1518.
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