WEEK #9: I-HUMAN CASE 26-YEAR-OLD FEMALE REASON FOR ENCOUNTER MORE FREQUENT SEVERE HEADA, Lab Reports of Integrated Case Studies

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WEEK #9: I-HUMAN CASE 26-YEAR-OLD

FEMALE REASON FOR ENCOUNTER

MORE FREQUENT SEVERE

HEADACHES UPDATED ON DECEMBER

2024 ALREADY GRADED A

lOMoAR cPSD| 22080904 lOMoAR cPSD| 220

• Bebe

• Treatment for migraines with aura

PHYSICAL EXAM FINDINGS

• General: Patient appears well-nourished and in no acute distress.
• Vital Signs: o Blood Pressure: [Insert value] (^) o Heart Rate: [Insert value] (^) o Respiratory Rate:

[Insert value] (^) o Temperature: [Insert value] o Oxygen Saturation: [Insert value]

• Head and Neck: No trauma or deformities. Neck is supple without lymphadenopathy or thyromegaly.
• Neurological: o Cranial nerves II-XII intact. (^) o Normal motor strength in all extremities. o Deep tendon reflexes are normal and symmetric. (^) o No sensory deficits noted. o Gait is normal.
• Eyes: Pupils are equal, round, and reactive to light. No papilledema observed.
• Cardiovascular: Heart sounds are regular, no murmurs or rubs.
• Respiratory: Lungs are clear bilaterally, no wheezes or crackles.
• Abdomen: Soft, non-tender, no hepatosplenomegaly.
• Primary Diagnosis: Tension headaches or migraines

ASSESSMENT

including abnormalities in sodium, potassium, or blood glucose]

• Thyroid Function Tests (TFTs): [Insert results, if applicable]
• Brain Imaging (CT/MRI): [Indicate if normal or if there are abnormalities like masses or hemorrhages]
• Electrocardiogram (ECG): Normal sinus rhythm, no abnormalities.
• Lumbar Puncture (if indicated): [Insert findings if performed, focus on CSF results]

1. Acute Management: (^) o Pharmacologic:  NSAIDs (e.g., ibuprofen or naproxen) or acetaminophen for mild headaches.  Triptans for suspected migraines (e.g., sumatriptan 50 mg PO).  Antiemetics if nausea is present (e.g., ondansetron 4 mg PO). o Preventive therapy for frequent migraines may

PLAN

include:  Beta-blockers (e.g., propranolol).  Antidepressants (e.g., amitriptyline).  Anticonvulsants (e.g., topiramate). o Muscle Relaxants: For tension-type headaches.

2. Non-Pharmacologic: o Encourage relaxation techniques (e.g., biofeedback, cognitive-behavioral therapy). (^) o Stress management interventions, including adequate sleep hygiene. (^) o Dietary changes to avoid migraine triggers (e.g., caffeine, certain foods).
3. Follow-Up: o Return visit in 2-4 weeks to reassess headache frequency and effectiveness of treatment. (^) o If symptoms worsen or new neurological signs develop, immediate imaging will be ordered (MRI brain, CT head).
4. Further Evaluation: o Referral to a neurologist if headaches do not improve with initial treatment or if imaging suggests concerning pathology. (^) o Physical therapy referral if cervicogenic headache is suspected.