Sally’s Headaches
Purpose:
The purpose of this Assignment is to enhance knowledge the evaluation and
management of acute versus chronic presentation of headache.
Case Study Description:
Sally Jones, 45 years old, presents to the primary care clinic with complaint of a headache. She says the headache usually comes when she is at work. She works as an administrative assistant for a chief Executive Officer at a local hospital. The headache is usually generalized and bilateral and most of the intensity of pain is around the neck or the back of her head. Sally says, “When the pain comes it is like a tight band around my head.” She says the headaches have been occurring more frequently over the past 30 days. Sally takes “homeopathic” tea she recently bought on her most recent trip to Mexico to visit her family. She does not believe in taking medicine for pain because of the side effects.
Directions:
Based on the case study please provide a response to each of the following items:
- What are the pertinent subjective findings? What other questions would you ask Sally to gain more information about her headaches?
- Describe the focused physical assessment you will perform on this patient. Provide rationale for conducting the focused assessment and support with peer-reviewed scholarly references.
- Identify the diagnostic studies/tests you will order for this patient (if any). Provide scientific, evidence-based rationale from a nationally accepted clinical guideline to justify the diagnostic studies/tests you will order for this patient.
- Develop a list of three differential diagnoses for Sally’s symptoms. Prioritize the three differential diagnoses from the most serious diagnosis to the least significant diagnosis.
- What is the most likely diagnosis based on Sally’s history of present illness and chief complaint? Is this condition acute or chronic-provide your justification?
- Develop a comprehensive, holistic treatment plan including pharmacologic and non-pharmacologic therapies for this patient taking into consideration Sally’s health belief and cultural belief practices.
- Discuss the difference in your pharmacologic intervention in acute versus chronic presentation. How will your treatment change if your patient is an adolescent?
The length of this paper should be 2–3 pages, not including title page and a reference page.
Expert Solution Preview
Introduction:
The case study presented here describes the patient who complained of headaches. The main objective of this assignment is to enhance the knowledge and evaluation of acute versus chronic presentation of headache. The assignment requires a comprehensive assessment of the patient’s history and presentation, differential diagnosis, and a holistic treatment plan.
1. What are the pertinent subjective findings? What other questions would you ask Sally to gain more information about her headaches?
The pertinent subjective findings for Sally include her complaint of frequent headaches, their intensity, and how it affects her daily life. To gain more information about her headaches, we can ask about the following:
– Duration of the headaches
– Triggers for the headaches
– Location of the headache pain
– Associated symptoms, such as nausea or sensitivity to light
– Previous treatments for headaches
– Family history of headaches
2. Describe the focused physical assessment you will perform on this patient. Provide rationale for conducting the focused assessment and support with peer-reviewed scholarly references.
A focused physical assessment for headaches includes a neurological exam, blood pressure measurement, and an eye exam. The neurological exam assesses the cranial nerves, motor strength, reflexes, and sensation. Blood pressure measurement can help detect hypertension, which can lead to secondary headaches. An eye exam can detect papilledema, which can indicate increased intracranial pressure (ICP) and may need further evaluation with imaging. (Barry et al., 2020)
3. Identify the diagnostic studies/tests you will order for this patient (if any). Provide scientific, evidence-based rationale from a nationally accepted clinical guideline to justify the diagnostic studies/tests you will order for this patient.
The diagnostic studies/tests for Sally can include blood tests to check for anemia or infection, imaging studies, such as CT scan or MRI, and lumbar puncture if there is a suspicion of meningitis. Imaging studies are not usually needed for primary headaches but may be considered if a secondary headache is suspected based on the history and exam. (Mayo Clinic, 2021)
4. Develop a list of three differential diagnoses for Sally’s symptoms. Prioritize the three differential diagnoses from the most serious diagnosis to the least significant diagnosis.
The three differential diagnoses for Sally’s symptoms can be tension-type headache, migraine headache, or secondary headaches due to medication overuse or other underlying conditions. The most serious diagnosis is secondary headaches due to underlying pathology, such as a brain tumor, infections, or increased intracranial pressure. The least significant diagnosis may be tension-type headaches.
5. What is the most likely diagnosis based on Sally’s history of present illness and chief complaint? Is this condition acute or chronic-provide your justification?
Based on Sally’s history of present illness and chief complaint, the most likely diagnosis is tension-type headache. Tension-type headaches usually occur in both sides of the head and can be triggered by stress or anxiety. Her symptoms are chronic, as she reports more frequent headaches over the past 30 days.
6. Develop a comprehensive, holistic treatment plan including pharmacologic and non-pharmacologic therapies for this patient taking into consideration Sally’s health belief and cultural belief practices.
The treatment plan for Sally can include non-pharmacologic therapies, such as stress reduction techniques, regular exercise, and relaxation techniques. Pharmacologic therapies can include over-the-counter pain relievers, such as ibuprofen or acetaminophen, or prescription medications, such as muscle relaxants or tricyclic antidepressants. It is important to consider Sally’s health beliefs and cultural practices when forming the treatment plan, such as her reluctance to take medications due to side effects. In such cases, alternative therapies can be explored, such as acupuncture or herbal remedies.
7. Discuss the difference in your pharmacologic intervention in acute versus chronic presentation. How will your treatment change if your patient is an adolescent?
The pharmacologic interventions for acute and chronic presentation of headaches differ in terms of medications and dosages. Acute presentations usually require immediate relief and can be treated with over-the-counter pain medications or prescription triptans. For chronic presentations, preventive medications, such as beta-blockers, topiramate, or amitriptyline, can be used to reduce the frequency and severity of headaches. The dosage of medications may also differ based on the type and severity of headaches. If the patient is an adolescent, the treatment plan needs to be adjusted based on their developmental stage and potential medication side effects. (American Headache Society, 2021)
References:
American Headache Society. (2021). Pediatric Headache: A Clinical Guide. https://americanheadachesociety.org/wp-content/uploads/2021/07/Pediatric-Headache-A-Clinical-Guide.pdf
Barry, D., Mathews, T. D., & Gordhan, A. (2020). Headache. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK553222/
Mayo Clinic. (2021). Headache – Diagnosis and treatment. https://www.mayoclinic.org/diseases-conditions/headache/diagnosis-treatment/drc-20378545
