Latest 2025 October # Week 9 Comprehensive iHuman Case Study: 26-Year Old Female Patient, Exams of Integrated Case Studies

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Latest 202 5 October # Week 9

Comprehensive iHuman Case Study: 26 - Year-

Old Female Patient with More Frequent

Severe Headaches (Class 6512)

Patient Information Name: Kathleen Parks Age: 26 years Gender: Female Occupation: Graphic Designer Chief Complaint (CC): “I’ve been having more frequent and severe headaches that are really affecting my life.” Setting: Outpatient Primary Care Clinic Date of Encounter: October 2024 (Week 9, NURS 6512)

1. History-Taking (Subjective Data) Chief Complaint Kathleen Parks, a 26-year-old female, presents with a chief complaint of increasingly frequent and severe headaches over the past three months, significantly impacting her daily functioning and work performance as a graphic designer. History of Present Illness (HPI) Using the OLD CARTS mnemonic, a detailed history was obtained to characterize the headaches and identify potential triggers or underlying causes: Onset: Headaches began approximately three months ago, initially occurring 1–2 times per week but progressing to near-daily episodes over the past month. Location: Predominantly unilateral, often starting at the right or left temple or behind the eye, with occasional bilateral involvement. Duration: Episodes last 4–12 hours, with some persisting into the next day if untreated. Characteristics: Described as throbbing, pulsating pain, rated 7–8/10 on the pain scale at peak intensity. Patients report a “tight band” sensation during severe episodes.

Aggravating Factors: Stress from work deadlines, exposure to bright lights (e.g., computer screens), loud noises, and sleep deprivation exacerbate symptoms. Prolonged screen time (8–10 hours daily) is a significant trigger. Relieving Factors: Ibuprofen 400 mg (OTC) provides partial relief (reduces pain to 4/10), as does resting in a dark, quiet room. Cold compresses occasionally help. Timing: No consistent diurnal pattern; headaches occur at various times, though often worse in the late afternoon or evening after long work hours. Severity: Pain is debilitating, forcing Kathleen to miss work or social activities 2–3 times per week. She reports difficulty concentrating and completing tasks. Associated Symptoms: Neurological: Visual disturbances described as “flashing lights” or “zigzag lines” (auras) precede ~30% of headaches, lasting 20–30 minutes. Occasional dizziness accompanies severe episodes. Gastrointestinal: Nausea during severe headaches, with one episode of vomiting reported. Sensory: Photophobia and phonophobia consistently present during episodes. Psychological: Increased irritability and difficulty focusing due to pain and fatigue. Past Medical History (PMH) No chronic medical conditions (e.g., hypertension, diabetes, or thyroid disease). No history of migraines or other headache disorders prior to three months ago. No recent head trauma, seizures, or neurological conditions. No hospitalizations or surgeries. Immunizations up to date, including annual influenza vaccine. Medications Ibuprofen 400 mg orally as needed for headaches, taken 2–3 times daily during severe episodes (up to 1200 mg/day).

Gastrointestinal: Nausea with headaches, rare vomiting, no abdominal pain or changes in bowel habits. Musculoskeletal: No joint pain, stiffness, or muscle weakness. Psychiatric: Reports increased stress and anxiety related to work, no depression or suicidal ideation. Endocrine: No heat/cold intolerance, excessive thirst, or hair/skin changes. Hematologic: No easy bruising or bleeding. Dermatologic: No rashes or lesions. Problem Statement Kathleen Parks is a 26-year-old female graphic designer presenting with a 3- month history of frequent (near-daily), severe (7–8/10), throbbing headaches, predominantly unilateral, associated with nausea, photophobia, phonophobia, and visual auras in ~30% of episodes. Symptoms are triggered by stress, bright lights, noise, and prolonged computer use, partially relieved by ibuprofen 400 mg and rest in a dark room. She reports significant disruption to work and social life. Past medical history is unremarkable, but her mother has a history of migraines. Social history includes high occupational stress, irregular sleep (5–6 hours/night), and caffeine use (2– 3 cups/day). Frequent ibuprofen use raises concern for medication-overuse headache.

2. Physical Examination (Objective Data) A focused physical exam was conducted to evaluate neurological function and rule out red flags for secondary headaches (e.g., intracranial pathology, meningitis). Vital Signs Blood Pressure: 118/76 mmHg Heart Rate: 72 beats/min, regular Respiratory Rate: 16 breaths/min Temperature: 98.6°F (37°C) Oxygen Saturation: 98% on room air Height: 5’5” (165 cm)

Weight: 130 lbs (59 kg) BMI: 21.6 kg/m² (normal) General Appearance Well-groomed, alert, no acute distress at rest, but appears fatigued and mildly anxious. HEENT Head: Normocephalic, atraumatic, no scalp tenderness or masses. Eyes: Pupils equal, round, reactive to light and accommodation (PERRLA). No nystagmus. Fundoscopic exam normal, no papilledema, hemorrhages, or exudates. Ears: Tympanic membranes clear bilaterally, no effusion. Nose: No congestion or discharge. Throat: Pharynx clear, no erythema or exudates. Neck Supple, full range of motion, no stiffness or meningismus. No cervical lymphadenopathy or thyroid enlargement. Neurological Mental Status: Alert and oriented to person, place, and time. Normal speech, appropriate affect, no cognitive deficits. Cranial Nerves: CN II: Visual acuity 20/20 bilaterally (corrected with glasses). CN III, IV, VI: Extraocular movements intact, no diplopia. CN V: Normal facial sensation, intact corneal reflex. CN VII: No facial asymmetry, normal smile. CN VIII: Normal hearing to finger rub. CN IX, X: Normal gag reflex, no dysphagia. CN XI: Normal shoulder shrug and head turn. CN XII: Tongue midline, no fasciculations. Motor: 5/5 strength in all extremities, no tremors or involuntary movements. Sensory: Intact to light touch, pinprick, and vibration bilaterally.

hallmark features of migraine with aura, as per the International Classification of Headache Disorders (ICHD-3). The family history of migraines (mother) and triggers like stress, bright lights, and sleep deprivation strongly support this diagnosis. The chronicity (near-daily) suggests possible chronic migraine. Probability: High due to classic symptoms and absence of red flags. Tension-Type Headache Rationale: Frequent headaches associated with stress and prolonged computer use could indicate tension-type headaches. However, the throbbing nature, nausea, and auras are less typical, making this diagnosis less likely. Probability: Moderate, as stress is a significant factor, but migraine features predominate. Cluster Headache Rationale: Severe, unilateral headaches could suggest cluster headaches, but the absence of autonomic symptoms (e.g., lacrimation, nasal congestion) and longer duration (hours vs. 15–180 minutes) make this less likely. Cluster headaches are also more common in males. Probability: Low due to atypical features and patient demographics. Intracranial Pathology (e.g., Brain Tumor, Hemorrhage) Rationale: Progressive, severe headaches warrant consideration of serious causes like mass lesions or hemorrhage. However, the normal neurological exam, absence of papilledema, focal deficits, or morning headaches, and 3- month duration reduce this likelihood. Probability: Low but must be ruled out due to severity and chronicity. Medication-Overuse Headache (MOH) Rationale: Frequent use of ibuprofen (2–3 times daily) raises concern for MOH, which can exacerbate primary headaches like migraines. The patient’s reliance on OTC analgesics aligns with this possibility. Probability: Moderate, likely contributing to chronicity rather than primary cause. Pheochromocytoma

Rationale: Rare cause of headaches associated with episodic hypertension, palpitations, and anxiety. Normal blood pressure (118/76 mmHg) and lack of paroxysmal symptoms make this unlikely. Probability: Very low, included for completeness due to severe headache presentation. Temporal Arteritis Rationale: Severe headaches and fatigue could suggest temporal arteritis, but the patient’s young age (26) and absence of jaw claudication, temporal tenderness, or systemic symptoms (e.g., fever, weight loss) make this unlikely. Probability: Very low, but inflammatory markers are warranted to rule out in atypical cases. Cervicogenic Headache Rationale: Prolonged computer use and poor ergonomics could contribute to neck-related headaches. However, the absence of neck pain or stiffness and presence of migraine-specific symptoms (auras, nausea) make this less likely. Probability: Low, but ergonomic factors may exacerbate symptoms.

4. Diagnostic Testing Diagnostic tests are selected to confirm the most likely diagnosis (migraine with aura), rule out serious secondary causes, and address potential contributing factors. Tests are prioritized based on clinical guidelines (e.g., American Academy of Neurology, UpToDate) and cost-effectiveness. Complete Blood Count (CBC): Purpose: Rule out anemia or infection contributing to fatigue or headaches. Expected Result: Likely normal, given no systemic symptoms. Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP): Purpose: Screen for temporal arteritis or other inflammatory conditions, though unlikely given age. Expected Result: Normal, but elevated levels would prompt further investigation.

Avoiding unnecessary tests (e.g., EEG, unless seizures are suspected) maintains efficiency, a key scoring factor in iHuman.

5. Management Plan The management plan addresses the primary diagnosis (migraine with aura), potential medication-overuse headache, and contributing factors (stress, sleep, ergonomics), following evidence-based guidelines (American Academy of Neurology, American Headache Society, UpToDate). Acute Management Sumatriptan 50 mg Oral at Onset: Purpose: First-line triptan for acute migraine relief, effective for moderate- to-severe headaches with aura. Instructions: Take at headache onset, repeat after 2 hours if needed (max 200 mg/day). Avoid if contraindications (e.g., uncontrolled hypertension, ischemic heart disease). Rationale: Proven efficacy in aborting migraine attacks (AAN Level A evidence). Supportive Measures: Rest in a dark, quiet room during episodes to reduce photophobia and phonophobia. Apply cold compress to forehead or neck for additional relief. Ensure adequate hydration (aim for 2–3 L water/day) to prevent dehydration-related exacerbation. Preventive Management Given near-daily headaches, preventive therapy is indicated to reduce frequency and severity. Topiramate 25 mg Daily: Purpose: First-line prophylactic therapy for chronic migraine (AAN Level A). Reduces neuronal hyperexcitability. Instructions: Start at 25 mg nightly, titrate by 25 mg/week to target 100 mg/day (50 mg twice daily) over 4 weeks. Monitor for side effects (e.g., paresthesia, cognitive slowing).

Rationale: Effective for reducing migraine frequency, especially in patients with frequent attacks. Alternative Options (if Topiramate Intolerated): Propranolol 20 mg twice daily, titrate to 80–160 mg/day (AAN Level A). Amitriptyline 10 mg nightly, titrate to 25–50 mg (AAN Level B), especially if anxiety is prominent. Address Medication-Overuse Headache Limit Ibuprofen Use: Instructions: Restrict ibuprofen to no more than 2 days/week to prevent MOH, as per ICHD-3 criteria. Alternative: Use sumatriptan for acute attacks and focus on preventive strategies. Rationale: Frequent analgesic use (>10–15 days/month) can perpetuate chronic headaches. Lifestyle Modifications Stress Management: Recommend mindfulness-based stress reduction (MBSR) or cognitive behavioral therapy (CBT) to address work-related stress. Suggest apps like Headspace or Calm for guided meditation. Rationale: Stress is a major migraine trigger; psychological interventions reduce attack frequency (AAN Level B). Sleep Hygiene: Establish a consistent sleep schedule (7–8 hours/night). Avoid screens 1 hour before bed and maintain a relaxing bedtime routine. Rationale: Sleep deprivation exacerbates migraines; improved sleep reduces triggers. Dietary Modifications: Reduce caffeine to 1 cup/day to minimize rebound effects. Maintain a headache diary to identify dietary triggers (e.g., MSG, aspartame). Ensure regular meals to avoid hypoglycemia.

Suggest a headache diary to track frequency, triggers, and treatment response. Follow-Up Schedule: Follow-up in 4 weeks to assess response to topiramate, review headache diary, and adjust treatment if needed. Monitoring: Check for side effects of medications and improvement in headache frequency/severity. Lab Follow-Up: Review MRI and blood test results; repeat CMP in 3 months if on topiramate to monitor electrolytes. Referrals Neurology: For MRI interpretation or if headaches are refractory to initial treatment. Behavioral Health: Refer to a therapist for CBT or stress management training. Occupational Health (Optional): For workplace ergonomic assessment if symptoms persist.

6. Documentation iHuman Patient Chart HPI: 26 - year-old female presents with a 3-month history of frequent (near- daily), severe (7–8/10), throbbing headaches, often unilateral, with nausea, photophobia, phonophobia, and visual auras (~30% of episodes). Triggers include stress, bright lights, noise, and sleep deprivation. Partially relieved by ibuprofen 400 mg and rest. Symptoms disrupt work and social life. PMH unremarkable; mother has migraines. Social history includes high stress, 5– 6 hours sleep/night, 2–3 cups coffee/day. Physical Exam: BP 118/76, HR 72, RR 16, Temp 98.6°F, SpO2 98%. Normal neurological exam, no papilledema, meningismus, or focal deficits. Mild fatigue noted. Problem Statement: As above.

Differential Diagnosis: Migraine with aura (primary), tension-type headache, cluster headache, intracranial pathology, medication-overuse headache, pheochromocytoma, temporal arteritis, cervicogenic headache. Diagnostic Tests: CBC, ESR, CRP, CMP, TSH, Free T4, brain MRI without contrast. Conditional: plasma metanephrines if paroxysmal symptoms emerge. Management Plan: Sumatriptan 50 mg PRN for acute attacks, topiramate 25 mg daily (titrate to 100 mg), limit ibuprofen to 2 days/week, stress management (MBSR/CBT), sleep hygiene, reduced caffeine, ergonomic adjustments, headache diary, follow-up in 4 weeks, neurology referral if needed. Headache Diary Template To enhance patient self-management and provide a practical tool for tracking headaches, the following template is recommended: Dat e T i m e S t a r t D u r a ti o n S e v e r i t y ( 0 – 1 0 ) L o c a ti o n T r i g g e r s Sy mp to ms (Na use a, Aur a, etc. ) Tre at me nt Use d R e l i e f ( Y / N ) N o t e s MM /DD /YY YY H H : M M H o u r s R / L / B o t h S t r e s s , L i Na use a, Pho top hob ia, Aur a Su ma trip tan , Res t, etc. Y / N

The case highlighted the interplay of lifestyle factors (stress, sleep, screen time) and medication overuse in chronic headache syndromes, prompting a holistic management plan that combined pharmacological and non- pharmacological interventions. I learned the importance of patient education and empowerment, such as using a headache diary to identify triggers, which enhances long-term outcomes. The iHuman platform’s emphasis on efficiency challenged me to balance thoroughness with targeted testing, avoiding unnecessary procedures like CT or lumbar puncture in the absence of red flags. This experience reinforced the value of evidence-based practice, drawing on AAN and AHS guidelines to select sumatriptan and topiramate. It also emphasized the role of interdisciplinary care, including referrals to neurology and behavioral health, to address complex needs. Moving forward, I will prioritize patient-centered communication and lifestyle interventions in managing chronic conditions, ensuring both clinical accuracy and empathy in practice.

8. Tips for Achieving an A Grade in iHuman Adhere to the Rubric: Ensure all required sections (HPI, exam, problem statement, differential, tests, plan) are complete, concise, and aligned. Review the NURS 6512 Week 9 rubric for specific criteria. Evidence-Based Practice: Reference authoritative sources (e.g., AAN, AHS, UpToDate) to justify diagnostic and treatment decisions, demonstrating scholarly rigor. Efficiency in iHuman: Avoid excessive history questions or tests (e.g., irrelevant labs) to maximize scoring for efficiency. Clinical Reasoning: Clearly link history and exam findings to the differential diagnosis and management plan, showing logical progression. Professional Documentation: Use precise medical terminology, avoid abbreviations unless standard (e.g., BP, HR), and ensure consistency across chart sections.

Patient-Centered Care: Include patient education and follow-up plans to demonstrate holistic care, a key component of advanced practice nursing. Reflection: Provide a thoughtful reflection that connects the case to learning objectives, such as clinical reasoning, patient safety, and evidence-based practice.

9. Additional Considerations Cultural and Social Factors Cultural Competence: Ensure communication is sensitive to Kathleen’s lifestyle as a young professional woman, acknowledging the impact of work- related stress on her health. Health Literacy: Use clear, jargon-free language when explaining the diagnosis and treatment plan to enhance adherence. Social Determinants: Address barriers like long work hours and limited time for exercise or therapy, suggesting flexible solutions (e.g., online CBT apps). Potential Complications Medication Side Effects: Monitor for topiramate side effects (e.g., cognitive slowing, weight loss) and sumatriptan contraindications (e.g., cardiovascular risks). Chronic Migraine Progression: Without intervention, frequent headaches may lead to chronic migraine (>15 days/month), requiring escalated therapy. Mental Health Impact: Chronic pain and stress may increase risk of anxiety or depression, warranting screening at follow-up. Alternative Diagnoses and Contingency Plans If MRI Reveals Abnormality: Refer to neurosurgery for structural lesions or neurology for further evaluation (e.g., Chiari malformation). If Topiramate Ineffective: Switch to propranolol or botulinum toxin (for chronic migraine, AAN Level A) after neurology consult. If MOH Confirmed: Implement a structured analgesic withdrawal plan with neurology guidance, using bridge therapy (e.g., prednisone taper). Technology and Tools