Evaluation and Management of Neurologic Conditions iHuman Beth Brown V5. 1PC PL

Chief Complaint: “I have worsening severe headaches”.

HPI: Ms. Brown, 16 y/o female presenting with more frequent, severe headaches start started 10-12 weeks ago, occurring every week. The headache presents unilaterally on the left side of the head and is felt behind the eye. Pain is rated 8-10/10 and prevents the patient from doing any activities, and sometimes the pain last up to 15 hours. She says she has a sensitivity to light, loud noises, nausea, and vomiting. The intense throbbing headache usually happens when there isn’t enough sleep or after eating junk food and chocolate with friends. She states before the headache there are visual distortions like “thin veils” at the edges. The headaches are relieved by a dark room and sleep. She also has a less severe secondary headache described as “band-like” involving the entire head, neck, and shoulders that is relieved by hot showers. She believes the secondary headache is due to her position when studying. Her mom has a history of headaches.

PMHx (child/adult illness/hospitalizations/immunizations)

ü  No medical issues

ü  No prior surgery

ü  No OB/GYN issues – menstruation is regular and no issues G0P0

ü  Wears helmet when biking

ü  Plays sports – soccer

ü  Nutrition: “regular American diet”; tries to minimize junk food

ü  Immunizations: Up to Date except HPV, first dose of meningococcal at age 12, Tdap at age 12

SurgHx

None

FamHx Grandparents (if known)/Parents/siblings/children

ü  Father: Unknown

ü  Mother: Longstanding headaches

ü  Siblings: None Spouse/offspring: N/A

SHx (Tobacco/vaping/ETOH/illicit drug use/occupational/environmental/relationships)

ü  Lives with mother in single parent home Housing: single-occupancy apartment

ü  Student: gets straight “As”

ü  Substance use: no smoking, no alcohol, no recreational drugs

ü  Denies being sexually active

Reproductive Hx

Female: Menarche unknown dates Last period 2 weeks ago

Not sexually active

Allergies (Food, Drug, Environmental, etc) NKA

List of Current Medications/supplements (prescription, OTC, complementary alternative therapies)

ü  Acetaminophen or Advil PRN for headaches

ü  Excedrin as needed

ü  Benadryl PRN for sleep

Review of Systems: (ROS) Use this column to document the ROS below.

General: Denies any problems with fatigue, difficulty sleeping unintentional weight loss or gain, and night sweats

Skin/Breasts: Denies any problems with itchy dry scalp, skin changes, moles, thinning hair, or brittle nails. Denies any breast discharge, lumps, scaly nipples, pain swelling, or redness Eyes: States “visual distortions, blurry wiggly stuff at the edges of eyes, like a “thin veil” ENT: Denies any drainage, swelling, redness Pulmonary: Denies SOB at night or at rest or when lying down, denies cough, wheezing or difficulty catching breath, chronic cough or sputum production

CV: Denies palpitations, pain or discomfort, heavy feeling or sensation of a “pounding heart

GI: Denies constipation, or heartburn. States normal bowel movements, states nausea, and vomited once with headache

GU: Denies pain, burning, blood in urine, denies difficulty starting or stopping urinating, dribbling, incontinence, urgency during night or day, or any changes in the frequency of urination

MS: Denies muscle weakness, joint pain, stiffness, redness or swelling Heme: Denies bruising, bleeding gums, nose bleeds, abnormal bleeding, or history of anemia Endocrine: Denies heat and cold intolerance, increased thirst, increased sweating, frequent urination, or changes in appetite

Neuro: Denies dizziness, lightheadedness, fainting, room spinning, seizures, or weakness. States “more frequent, severe headaches start started 10-12 weeks ago, occurring every week”, headache presents unilaterally on the left side of the head and is felt behind the eye, pain is rated 8-10/10 . She says she has a sensitivity to light, loud noises, nausea, and vomiting. She states before the headache there are visual distortions like “thin veils” at the edges. She also has a less severe secondary headache described as “band-like” involving the entire head, neck, and shoulders Psych: Denies anxiety, depression, loss of energy or changes in interests

From the ROS: list/highlight the current symptoms/complaints to generate a list of pertinent “reported or denied” symptoms below:

ü  Eyes: States “visual distortions, blurry wiggly stuff at the edges of eyes, like a “thin veil”

ü  GI: Denies constipation, or heartburn. States normal bowel movements, states nausea, and vomited once with headache.

ü  Neuro: Denies dizziness, lightheadedness, fainting, room spinning, seizures, or weakness. States “more frequent, severe headaches start started 10-12 weeks ago, occurring every week”, headache presents unilaterally on the left side of the head and is felt behind the eye, pain is rated 8-10/10.

ü  She says she has a sensitivity to light, loud noises, nausea, and vomiting. She states before the headache there are visual distortions like “thin veils” at the edges. She also has a less severe secondary headache described as “band-like” involving the entire head, neck, and shoulders

Physical Exam: (PE) Use this column to document the PE below.

ü  Height: 5′ 6″ (168.0 cm)

ü  Weight: 122 lb (55.0 kg) (BMI 19.7) Temperature: 98.6 F (oral)

ü  Pulse: 74 bpm – regular

ü  Blood pressure: 118/68 mmHg – supine/sitting

ü  Blood pressure: 116/62 mmHg – upon standing Respiratory rate: 12 bpm

ü  SpO2: 99% on room air

ü  General: Thin, pleasant, cooperative female, alert and oriented x4

ü  Skin/Breast: Warm, dry and intact, no redness, lesions, or bumps noted

ü  Breasts: Deferred

ü  HEENT: Eyes: Lashes without crusting, eyelids without edema, erythema. Conjunctivae pink, no discharge. No orbital edema, redness, tenderness. Ears: Pinna and tragus without tenderness upon manipulation bilaterally. Canals are clear bilaterally, tympanic membrane pearly, translucent, and pinkish-gray in color with intact landmarks bilaterally. Nose: Nares patent bilaterally, no nasal drainage or polyps, septum midline and intact, no edema or tenderness over frontal or maxillary sinuses, Sinuses non-tender to light percussion, no temporal artery tenderness. Neck: No visible scars, deformities, or lesions, the trachea is midline and mobile, no cervical mass or regional lymphadenopathy, full cervical-spine ROM

ü  Pulm: Respirations even and unlabored bilaterally, good chest wall expansion, lung sounds clear to auscultation bilaterally both anterior and posterior

ü  CV: Heart rate and rhythm normal, no significant change while standing, squatting and during Valsalva maneuver, no JVD. 2+ peripheral pulses x4 extremities, PMI in the 5th intercostal (ICS) at the midclavicular line (MCL) GI: Lean, non-distended, no scars noted, bowel sounds audible in all 4 quadrants, no hepatosplenomegaly, the spleen is non-palpable, no mass or herniation upon palpation, no abnormal pulses noted GU: Deferred

ü  Neuro: CN II-XII grossly intact, normal gait and posture, no involuntary movements noted patellar and brachial reflexes 2+ bilaterally, no facial asymmetry

ü  MSK: No tenderness, muscular resistance, rigidity, asymmetry, or deformity noted, ROM is equal bilaterally on upper and lower extremities

ü  Lymph: No pathologically enlarged lymph nodes in the cervical, supraclavicular, axillary, or inguinal chains

ü  Heme: Deferred Psych: Cooperative, calm, friendly, answered all questions without hesitancy, no anxiety, distress or sadness noted

From the PE: list/highlight the presence or absence of objective findings to generate a list of pertinent “(+) or (-)” symptoms below: Pertinent (-) Eyes: Lashes without crusting, eyelids without edema, erythema. Conjunctivae pink, no discharge. No orbital edema, redness, tenderness Nose: Nares patent bilaterally, no nasal drainage or polyps, septum midline and intact, no edema or tenderness over frontal or maxillary sinuses, Sinuses non-tender to light percussion, no temporal artery tendernes Neck: No visible scars, deformities, or lesions, the trachea is midline and mobile, no cervical mass or regional lymphadenopathy, full cervical-spine ROM Neuro: CN II-XII grossly intact, normal gait and posture, no involuntary movements noted patellar and brachial reflexes 2+ bilaterally, no facial asymmetry MSK: No tenderness, muscular resistance, rigidity, asymmetry, or deformity noted, ROM is equal bilaterally on upper and lower extremities

Lab/Radiology or other Diagnostic data reviewed today during virtual visit

Problem Statement: Ms. Brown, 16 y/o female student presenting with more frequent, severe headaches start started 10-12 weeks ago, occurring every week. The headache presents unilaterally on the left side of the head and is felt behind the eye. Pain is rated 8-10/10 and prevents the patient from doing any activities, and sometimes the pain last up to 15 hours. She says she has a sensitivity to light, loud noises, nausea, and vomiting. The intense throbbing headache usually happens when there isn’t enough sleep or after eating junk food and chocolate with friends. She states before the headache there are visual distortions like “thin veils” at the edges. The headaches are relieved by a dark room and sleep, Tylenol or Advil. She also has a less severe secondary headache described as “band-like” involving the entire head, neck, and shoulders that is relieved by hot showers. She believes the secondary headache is due to her position when studying. Her mom has a history of headaches. Upon examination there were no neurological changes noted, physical exam was unremarkable with no pertinent positives supporting her complaints

List the differential diagnoses (Must not Miss/Leading/Alternate/Concluding – total of 3 *Include ICD 10 codes after each

1. Migraines G43.909- LEADING (MUST NOT MISS, if one had to be selected)- Beth Brown reported having unilateral severe headaches that lasted up to 15 hours accompanied by   visual distortions, blurry wiggly stuff at the edges of eyes that felt like a “thin veil”. She describes the headache as throbbing in nature with associated symptoms of vomiting (1 episode) and nausea. According to Orr et al (2017), these symptoms are characteristic of migraines and the visual sensory symptoms are   collectively known as   aura. Besides, migraines occur more commonly in women, they have a strong genetic predisposition and are triggered by caffeine and chocolate intake. Beth Brown was female; she had a familial history of headaches (mother) and admitted to taking chocolate. Collectively, these factors increase her risk to migraines as the most likely primary diagnosis

2. Tension headache G44.209. ALTERNATE- patient’s often report a headache of throbbing nature with a gradual onset and less severity. It primarily occurs in the frontal-occipital location, is bilateral with mild-moderate intensity with a tightening/pressing quality. Although patients may report nausea, phonophobia or photophobia, there is no vomiting (Fattahzadeh-Ardalani et al., 2017). The onset of duration usually ranges between 30 minutes to 7 days. Tension headaches are mildly-moderately painful but are less harmful such that, they do not interfere with the normal life and work of an individual. On physical exam, patients have weak neck extension muscles.  Although Beth Brown reported a headache of throbbing nature which felt like a “band-like” with photophobia, she confirmed that it was unilateral; it impaired her ability to perform ADLs. Besides, she also reported one episode of vomiting which generally decreases the likelihood of this diagnosis.

3. Cluster headache G44.0. ALTERNATE- According to the American Headache Society, cluster headaches, commonly known as histamine headaches involve a grouping of headaches that occur   over a period of numerous weeks. Patients report severe-very severe attacks of unilateral pain lasting 15-80 minutes which can occur once daily   to 7/8 times daily (Robbins et al, 2016). The headache episodes may be associated with   one or several of symptoms such as   conjunctival injection, nasal congestion, eyelid edema, lacrimation, or rhinorrhea. Although the patient in this case acknowledged that her headaches were unilateral and very severe (8-10/10), she reported that they lasted up to 15 hours but denied other associated symptoms such as rhinorrhea, facial and forehead sweating, and nasal congestion. Besides, on physical exam, there were no findings that were suggestive of cluster headaches such as miosis, eyelid edema, ptosis or conjunctival injection.

Bacterial Meningitis G00.9-patients with bacterial meningitis will report symptoms of headaches, neck stiffness, nausea and vomiting, photophobia, and hotness of the body. Similarly, the patient Beth Brown reported symptoms of   severe headaches, nausea and vomiting, and photophobia. On physical exam, the findings will be consistent with fever, nuchal rigidity, a positive Kernign sign, and Brudzinski sign (signs of meningeal irritation) (Davis et al., 2018). However, since the patient reported no neck stiffness and on physical exam there were no findings of a fever and all joints had a full Range of Motion, this is a less likely diagnosis

Plan No lab or diagnostic workup necessary at this time

Medication options: Acetaminophen PO 325-650 mg q4-6 hours, NSAIDS or aspirin

Anti-nausea medication as needed such as Zofran, or Reglan Indomethacin PO 25-50 mg tid or qid (max 200 mg/day) Sumatriptan PO 25 mg Dihydroergotamine intranasal 1 spray (0.5mg) in each nostril, repeat with additional spray 15 min if no relief (max 4 sprays per attack), wait 6-8 hours before treating another attack Propanolol 80 mg/day PO Verapamil 80 mg PO q 6-8 hours Lisinopril 5-40 mg day PO Valproic Acid 250 mg BID PO Plan and Education: Avoid chocolate, caffeine, alcohol, smoke which are migraine triggers Rest Ice applied to the back of the neck Hot showers Reduce stress by yoga, meditation, biofeedback, CBT, massage therapy

Better sleep 8 hours a night Keep a headache diary to identify triggers Add exercise to the daily routine Consult or Referral: Possible Neuro or Psych consult if pain is not relieved in the next two weeks Follow up in 8 weeks to evaluate medication efficacy, and evaluation of treatment plan

Based on patient’s age/risk factors, what preventive screening would be recommended at today’s or a future visit: Possible safety screening (bullying/IPV if applicable/home safety) Depression Screening Dietary counseling: trigger foods for migraines Educate regarding healthy study habits, sleep habits, and healthy adolescent relationships