Perry Solomon iHuman More Frequent Severe Headaches

Perry Solomon iHuman More Frequent Severe Headaches

Reason for Encounter

More Frequent Severe Headaches

History of present illness (HPI)

A 26-year old female; Perry Solomon 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.  

History Questions

1. How can I help you today?
2. Do you have any other symptoms or concerns we should discuss?
3. Do you have a headache?
4. When did your headache start?
5. What are the events surrounding the start of your headache?
6. How long does your headache last?
7. Does your headache come and go?
8. Do you have new headaches that you have not experienced previously?
9. Any change in your headache since it began?
10. Where more precisely is the pain in your head?

Physical Exam 

1. Blood pressure
2. Pulse
3. Respiration
4. Temperature
5. Assess gait and stance
6. Inspect/palpate head(including scalp)
7. Palpate sinuses
8. Test visual acuity
9. Inspect eyes

Case Findings 

• 10 year history of stable-character headaches with recent increase in headache severity and frequency
• Preceding bilateral scintillating scotomas
• Nausea and vomiting with headache episodes
• Photophobia/phonophobia with headache episodes

Problem Statement

Perry Solomon 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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