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

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Latest 2025 October # Week 9 Comprehensive iHuman

Case Study: 26 - Year-Old Female Patient with More

Frequent Severe Headaches (Class 6512)

COMPLETE HISTORY

Case: Week #9 | Comprehensive i-Human Case Study Patient: 26 - Year-Old Female Presenting Complaint: Severe, frequent headaches

1. Chief Complaint (CC)

“I’ve been having really bad headaches almost every day. They’re getting worse and making it hard to function.”

2. History of Present Illness (HPI)

• 26 - year-old female presents with daily, worsening headaches for the past 3–4 weeks
• Headaches are described as pulsating and severe , rated 8 – 9/10 on average
• Location: Bilateral frontal and temporal areas, sometimes radiating behind the eyes
• Headaches last between 4 to 6 hours , with some lasting up to 12 hours
• Associated symptoms include: o Photophobia (light sensitivity) o Phonophobia (sound sensitivity) o Nausea (without vomiting) o Mild blurred vision during severe attacks , but no aura or visual field loss
• Reports no fever, no neck stiffness, no head trauma, and no neurologic deficits
• Denies any focal symptoms (e.g., weakness, numbness, speech changes)
• Reports significant work stress , poor hydration, and averaging only 4 – 5 hours of sleep/night
• Admits to consuming 3 – 4 cups of coffee daily
• Takes ibuprofen or acetaminophen , which provide only partial relief
• Denies history of similar headaches in the past, except for occasional tension-type headaches in college
• Very worried about a brain tumor due to frequency and severity

3. Past Medical History (PMH)

• No diagnosed chronic medical conditions
• No history of migraines or neurologic disorders previously
• G1P1 – one full-term vaginal delivery 2 years ago
• No history of seizures, head trauma, or recent infections
• No known medication allergies

Vital Result Blood Pressure 122/78 mmHg Heart Rate 78 bpm Respiratory Rate 16 breaths/min Temperature 98.6°F (37°C) Oxygen Saturation 99% on room air Weight Within normal BMI range

Neurological Exam

• Cranial Nerves II–XII: Intact
• Strength: 5/5 in all extremities
• Sensation: Intact to light touch, pinprick
• Reflexes: 2+ throughout, symmetric
• Coordination: Intact (finger-to-nose, heel-to-shin)
• Gait: Normal
• Romberg: Negative
• No nystagmus, no dysarthria
• No signs of papilledema on fundoscopic exam
• No focal neurological deficits

HEENT

• Head: Normocephalic, atraumatic
• Eyes: o Pupils equal, round, reactive to light o No visual field deficits o No redness, discharge, or photophobia observed during exam
• Ears: Tympanic membranes intact
• Nose: No sinus tenderness
• Throat: Oropharynx clear
• Neck: Supple, no meningeal signs (no nuchal rigidity)

Cardiovascular

• Regular rate and rhythm
• No murmurs, rubs, or gallops
• Peripheral pulses 2+ bilaterally

🫁 Respiratory

• Lungs clear to auscultation
• No wheezes, rales, or rhonchi
• Chest expansion symmetrical

GI/Abdominal

• Abdomen soft, non-tender
• No organomegaly or masses
• Normal bowel sounds

Musculoskeletal

• Normal muscle tone
• No tenderness or joint swelling
• Full ROM in neck, shoulders, limbs

REVIEW OF SYSTEMS (ROS) – FOCUSED

System Patient Reports General Fatigue, headaches, sleep deprivation Neuro Headaches, photophobia, phonophobia, mild visual changes (no aura, no weakness, no numbness) HEENT Mild eye strain, no sinus pain, no vision loss CV No chest pain, palpitations Resp No cough, shortness of breath GI Occasional nausea during headaches, no vomiting GU No urinary or menstrual complaints MSK Neck muscle tightness with severe headaches Skin No rashes or lesions Psych Stress, anxiety related to symptoms, no depression, no suicidal ideation

o Nausea o Photophobia o Phonophobia

• No evidence of structural or systemic cause
• No focal neurologic deficits on examination
• Family history of migraine (mother) supports primary headache disorder
• Normal vitals and normal physical/neuro exam findings Here is the complete and clinically appropriate section for:

Investigations & Lab Results

Patient: 26 - Year-Old Female Case: i-Human Week #9 – Severe, Frequent Headaches (October 2024 Update)

Purpose of Investigation

To:

• Rule out secondary causes (infection, bleeding, tumor)
• Evaluate for systemic or neurological red flags
• Guide treatment (e.g., pregnancy status, anemia)

Initial Labs Ordered

Investigation Result Interpretation Complete Blood Count (CBC) Normal No signs of infection, anemia, or inflammation Erythrocyte Sedimentation Rate (ESR) Normal No evidence of vasculitis, temporal arteritis Urine hCG (Pregnancy Test) Negative Rules out pregnancy as cause of hormonal or vascular headache Thyroid Stimulating Hormone (TSH) Normal Rules out thyroid dysfunction contributing to fatigue or headache Electrolytes Normal No metabolic disturbance contributing to symptoms

Imaging (As Needed Based on Clinical Concern)

Imaging Result Interpretation Head CT (Non- Contrast) Normal No signs of hemorrhage, mass lesion, hydrocephalus MRI Brain (if performed) Normal No evidence of tumor, vascular malformation, or intracranial pathology Imaging was considered due to new onset + severity , but no red flags or neurological signs were present, making advanced imaging optional.

Additional Screenings (Optional/Deferred)

Test Rationale Status Serum Ferritin/Iron Rule out restless leg syndrome-related fatigue or sleep disruption Not indicated — no relevant symptoms CRP Rule out systemic inflammation Deferred — ESR was normal Toxicology Screen Rule out substance-induced headaches Not indicated — no drug use history

Summary of Key Findings

• All lab tests are within normal limits
• No secondary cause identified
• Clinical + diagnostic data support a primary headache disorder , most consistent with migraine without aura Here is a professionally formatted SOAP Note for the i-Human Week #9 Case Study: 26 - Year-Old Female with Severe, Frequent Headaches (October 2024 Update) — suitable for clinical documentation, exams, or uploads.

SOAP Note

• Mother: Migraines
• Father: Hypertension
• No family history of tumors or seizures Social History:
• Works full-time as digital editor
• Lives alone
• High stress, irregular meals, poor sleep
• Drinks alcohol occasionally, no tobacco or drugs
• Sedentary lifestyle

O – Objective

Vital Signs:

• BP: 122/78 mmHg
• HR: 78 bpm
• Temp: 98.6°F
• RR: 16
• SpO₂: 99% RA Physical Exam:
• General: Alert, oriented, appears tired
• HEENT: No sinus tenderness; pupils equal/reactive; no papilledema
• Neuro: CN II–XII intact; no focal deficits; sensation/motor 5/
• Neck: Supple, no nuchal rigidity
• CV/Resp: Normal S1/S2; clear breath sounds
• MSK: No neck muscle tenderness
• GI: Abdomen soft, non-tender Investigations:
• CBC, ESR, TSH, Electrolytes: Normal
• Urine hCG: Negative
• CT Head: Normal (if done)
• MRI Brain: Not indicated unless symptoms worsen

A – Assessment

Primary Diagnosis: Migraine without Aura (G43.009)

• Meets ICHD-3 criteria: severe, recurrent, throbbing headache + photophobia, phonophobia, nausea
• No red flags; normal neuro exam Differential Diagnoses:
• Tension-type headache
• Cluster headache
• Medication-overuse headache
• Secondary headache (brain lesion) – ruled out clinically

P – Plan

1. Pharmacologic

• Sumatriptan 50 mg PO at headache onset
• Naproxen 500 mg PRN for pain not relieved by triptan
• Consider Propranolol 20 mg BID if attacks >4/month (preventive)

2. Non-Pharmacologic

• Headache diary – track triggers, frequency, severity
• Stress reduction – breathing techniques, breaks during screen time
• Improve sleep hygiene – fixed bedtime, screen-free evenings
• Caffeine reduction – taper intake to <1 cup/day
• Hydration and meal regularity

3. Education & Counseling

• Avoid overusing pain meds (risk of MOH)
• Recognize early symptoms and use abortive therapy promptly
• Red flag warning signs: sudden severe headache, neuro deficits, vision loss
• Reassure — imaging normal, migraine is manageable

4. Follow-Up

• 4 - week review: Response to meds, diary, frequency
• Consider neurology referral if unresponsive
• Assess for impact on quality of life, occupational functioning

3. Medical Treatment Plan

A. Abortive Therapy (First-line):

• Sumatriptan 50 mg PO at headache onset o May repeat after 2 hours if no relief o Max 200 mg/day
• Naproxen 500 mg PO as adjunct PRN if triptan alone is insufficient o Avoid daily use to reduce medication-overuse headache risk B. Preventive Therapy (if ≥4 attacks/month):
• Propranolol 20 mg BID , titrate as tolerated o Alternatives: Topiramate, Amitriptyline (if insomnia present) o Preventive therapy reduces intensity/frequency of future migraines C. Rescue Therapy (if triptan fails):
• Toradol IM (clinic setting) OR antiemetic (metoclopramide 10 mg PO/IM) o For in-office rescue or refractory attacks

4. Doctor’s Follow-Up Plan

• Schedule follow-up in 4 weeks : o Assess treatment response (frequency, severity) o Review headache diary o Evaluate tolerability of medications
• Consider neurology referral if: o Symptoms persist despite therapy o New neurological signs appear
• Monitor for medication overuse and psychological impact (anxiety, depression)
• Continue non-pharmacologic strategies and lifestyle adjustment Would you like this added to: Here are the professionally written Nursing Interventions, Goals, and Rationales for the: i-Human Week #9 Case Study 26 - Year-Old Female with Severe, Frequent Headaches (October 2024 Comprehensive Update – Final Diagnosis: Migraine Without Aura)

NURSING INTERVENTIONS, GOALS, AND

RATIONALES

Goal Intervention Rationale

1. Relieve Acute Headache Pain Administer prescribed abortive medication (e.g., Sumatriptan 50 mg PO at headache onset) Triptans are first-line agents that act on serotonin receptors to reduce migraine pain and inflammation. Early administration improves outcomes. 2. Reduce Frequency of Migraine Episodes Educate patient on headache triggers (e.g., caffeine, skipped meals, poor sleep) and maintain a headache diary Identifying and avoiding individual triggers reduces the likelihood of recurrent episodes. Diaries help personalize preventive strategies. 3. Promote Rest and Comfort Encourage patient to rest in a dark, quiet room during migraine attacks Sensory stimuli like light and noise can aggravate migraines. A calm environment helps reduce headache intensity. 4. Improve Medication Adherence and Prevent Overuse Provide clear instructions on when and how to take abortive and preventive medications Educating on proper use helps ensure efficacy and reduces the risk of medication-overuse headache (MOH). 5. Enhance Coping and Self-Management Teach relaxation techniques (e.g., deep breathing, guided imagery ) to manage stress Stress is a major migraine trigger. Teaching coping skills helps reduce frequency and promotes overall wellness. 6. Prevent Complications and Monitor Progress Monitor for red flag symptoms : visual disturbances, neurological changes, or worsening headaches Early recognition of complications (e.g., stroke, secondary headache) ensures timely medical intervention. 7. Support Lifestyle Changes Counsel patient to adopt regular sleep , adequate hydration , balanced meals , and physical activity Healthy lifestyle modifications are proven to reduce migraine incidence and improve quality of life. 8. Ensure Emotional Support Assess for anxiety, depression, and migraine-related disability ; offer referrals (e.g., counseling) if needed Migraines can be disabling and emotionally distressing. Early psychological support improves adherence and coping. Here is the Patient Education section for the:

Tip Why it Matters Practice stress management Try deep breathing, meditation, or yoga Take breaks from screens Bright lights or eye strain can trigger headaches

When to Seek Medical Help

Call your provider or go to the emergency department if you experience:

• Sudden, "worst headache of your life"
• Vision loss , slurred speech, confusion, or muscle weakness
• Headache after a head injury
• Fever , stiff neck, or rash with headache
• Frequent vomiting that prevents taking medications

Follow-Up Plan

• Return to clinic in 4 weeks to review your symptoms, diary, and how well medications are working
• Report any side effects or worsening symptoms immediately
• If symptoms continue or worsen, referral to a neurologist may be necessary

Encouragement

Migraines can be frustrating, but with the right treatment plan and awareness of your triggers, they can be controlled. You are not alone — and support is available. Here is a professionally written Reflection Report for your: i-Human Week #9 Comprehensive Case Study Patient: 26 - Year-Old Female with Severe, Frequent Headaches Diagnosis: Migraine Without Aura (October 2024 Update)

🫁 REFLECTION REPORT

What I Learned

This case highlighted the importance of approaching headaches with a structured, differential- based method. Although migraines are a common diagnosis, this patient’s presentation required ruling out life-threatening secondary causes such as intracranial mass, meningitis, or vascular events. I strengthened my understanding of the ICHD-3 diagnostic criteria for migraine, recognizing that the combination of pulsating pain, photophobia, phonophobia, and nausea without aura fits the diagnosis of migraine without aura. I also learned the importance of patient education, trigger identification , and lifestyle counseling as core components of migraine management— not just pharmacologic treatment.

Clinical Insight Gained

• Not all headaches are benign; "red flag" symptoms must always be screened for.
• The subjective history plays a critical role in diagnosing primary headache syndromes.
• The use of headache diaries and non-pharmacological interventions (e.g., sleep hygiene, stress reduction) are often underutilized but vital.
• It’s important to reassure patients when diagnostic workup is negative—especially in young adults fearful of brain tumors or neurological disorders.

Self-Reflection

Initially, I was quick to lean toward a diagnosis of tension headache due to her lifestyle and stress. However, after systematically reviewing her symptoms, duration, and associated features, it became clear that a migraine diagnosis was more appropriate. This taught me to avoid anchoring bias and instead follow evidence-based criteria when forming my assessment.

How I Will Improve

In future clinical encounters:

• I will be more thorough in trigger analysis and patient lifestyle review.
• I will emphasize the importance of early abortive treatment.
• I will practice clear communication and empathy , especially when a patient expresses anxiety about a possible serious illness.