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Case 1: Headaches
A 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw.
Patient Information:
S.O., 49 , Male, Asian
S.
CC Headache
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
Location: head, pain all over, pain is worse with pressure on the forehead, the nose, cheekbones, and jaw.
Onset: Intermittent for two months, more frequent one week.
Character: pounding dull ache with pressure
Associated signs and symptoms: nausea, photophobia, phonophobia
Timing: onset varies in time but most frequently in the evening after work.
Exacerbating/ relieving factors: cool rag on forehead helps slightly, light, and noise make it worse.
Severity: 8/10 pain scale
Current Medications: Fluticasone Propionate Nasal Spray 50 mcg sprayed in each nostril once daily for season allergies. OTC Acetaminophen 500 mg PO every 6 hours for pain.
Allergies: Latex, rash. Strawberries, rash.
PMHx: Appendectomy age 10 years old, L4-L5 lumbar spinal fusion 2008 and T2-T3 cervical spinal fusion 2010 both for degenerative disk disease. Tetanus vaccine 2007. Flu vaccine October 2017, reports up to date on all other vaccines. Soc Hx: Accountant and competitive dart thrower. Single, heterosexual, denies current sexual partner, states he has no interest in “dating” at this time. Denies smoking, exposed to second hand smoke at Dart competitions. Denies alcohol intake. Reports seat belt use while driving, denies guns in home, lives alone. Reports several caffeinated beverages daily, > 3 cups coffee and soda.
Fam Hx: Father living age 81, coronary artery disease, HTN, and skin cancer unknown type, Mother diseased age 71 breast cancer, Grandparents all diseased unknown health history, One sibling, living, brother age 55, CVA.
ROS:
GENERAL: Denies recent illness, weight loss or gain, denies any fevers, chills, or night sweats.
HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae, states that eyes are very sensitive to light during headaches. Ears: denies pain, discharge, or hearing changes. Nose: reports seasonal rhinorrhea, reports pain during headaches in sinus area, Throat: Denies pain, denies difficulty speaking or swallowing.
SKIN: Denies any open wounds, sores, lesions, rash, or bruising.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. Denies palpitations and edema.
RESPIRATORY: Denies shortness of breath, cough.
GASTROINTESTINAL: Reports anorexia with headaches, nausea, and vomiting.
GENITOURINARY: Denies burning on urination, increased frequency, or nocturea.
NEUROLOGICAL: Intermittent headaches, denies dizziness, denies syncope, denies paralysis, ataxia, numbness or tingling in the extremities. Denies changes in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle pain, back pain, joint pain or stiffness.
HEMATOLOGIC: Denies bleeding of gums, denies frequent bruising.
LYMPHATICS: Denies enlarged nodes.
PSYCHIATRIC: Reports history of depression and anxiety, has never sought treatment. Reports good mood recently.
ENDOCRINOLOGIC: Denies excessive thirst, hunger, or need to urinate.
ALLERGIES: Seasonal allergies with Rhinorrhea and sneezing, treated with nasal spray. Strawberries and Latex produce rash response.
O.
Physical exam:
General: BP138/784, P 86, T. 98.7, R 18 Psa02 98% room air. S.O. is a pleasant well fed, well groomed Asian male that presents with c.o. intermittent headache more severe over his eyes, nose, and into his jaw. Onset two month ago becoming more frequent this last week. Pt report photophobia, intolerance to sound, and nausea with occasional vomiting with headaches.
Head: Full range of motion of neck and head, Symmetric, no lesion or evidence trauma observed. Facial features symmetric, no tics, tremors, or drooping observed. Frontal and Maxillary sinus tender to palpation. Ears: Symmetric, patent, pearl grey tympanic membrane, no erythema present Eyes: Clear sclera, no discharge, pupil equal and reactive to light Nose: Mild clear rhinorrhea noted, both naris patent, septum intact, no deviation, bleeding, or crusts noted. Pale, boggy mucosa. Throat: No swelling of tonsils noted, pink, no erythema or excaudate noted. Post nasal drainage evident.
Neck: Symmetric, trachea aligned, no masses, webbing, or skinfolds noted. No palpable lymph nodes in neck. Thyroid gland palpated, no gross abnormalities.
Cardiovascular; Regular Rate and Rhythm, S1 and S2 presents, no advantageous sounds noted. No peripheral edema.
Respiratory: Lung sounds clear over all fields, no advantageous sounds noted.
Neurological: Answers question appropriately, oriented to person, place, and situation. Pupils equal and reactive to light. Grip strength equal both hands, face symmetric. Short term and long term memory intact. Headache rated 8/10 on pain scale intermittent. Photophobia, photophobia, nausea and vomiting present with headache.
Diagnostic results: Nasal smear/nasal scraping to look for eosinophils would confirm allergic rhinitis (Dains, Baumann, Scheibel, 2016). Patients with severe symptoms may indicate need for radiograph (Dains, Baumann, Scheibel, 2016). If the disorder does not respond to therapy may require a CT scan to determine the extend of the disease (Dains, Baumann, Scheibel, 2016). MRI is indicated in severe cases to see soft tissue pathology and brain tissue abnormality (Dains, Baumann, Scheibel, 2016). Sinus Aspiration is performed by otolaryngologists to confirm bacterial sinusitis (Dains, Baumann, Scheibel, 2016). An otolaryngologist may also perform a nasal endoscopy (Dains, Baumann, Scheibel, 2016). Allergy skin testing can be helpful in determining the reason for seasonal changes (Dains, Baumann, Scheibel, 2016).
A.
Differential Diagnoses
#1 Acute Sinusitis: Acute Rhinosinusitis causing symptomatic inflammation inside the nasal cavities lasting less than four weeks (Up-to-date, 2017). Common complaint of frontal headaches, with pressure or fullness feeling (Dains, Baumann, Scheibel, 2016). This disorder is usually worse during winter month, this patient reports season rhinitis treated with prescription nasal spray ((Dains, Baumann, Scheibel, 2016). This condition, as well as with post nasal drainage, usually complains of cough worse upon lying down which this patient does not have (Dains, Baumann, Scheibel, 2016). He does have tender sinuses with palpation and complains of pressure which fit this diagnosis criteria.
#2 Medication rebound headache: A chronic daily headache associated with medication or caffeine use (Up-to-date, 2017). Pain with this headache is often described as Holocranial or diffuse, it is associated with person’s using headache medication or caffeine intake on a daily basis, headache starts a few hours after the last dose of medication or caffeine (Ball, Dains, Flynn, Solomon, Stewart, 2015). This patient reports acetaminophen and substantial caffeine use on a daily basis.
#3 Migraine without aura: This is one of the most common complaints that patients are seen by a neurologist for (Up-to-date, 2017). Up to 20% of adults have migraines, it is a very common disorder (Dains, Baumann, Scheibel, 2016). Headache is usually unilateral and described as throbbing. Migraines often are accompanied by photophobia, phonophobia, nausea, and vomiting, all which this patient has reported. (Dains, Baumann, Scheibel, 2016).
#4 Rhinitis Medicamentosa: Rebound congestion can be caused by long term use of topical nasal decongestants which this patient reports using for seasonal allergies (Dains, Baumann, Scheibel, 2016). Long term use may result in vasoconstriction onside the naris described as pressure and congestion (Dains, Baumann, Scheibel, 2016).
#5 Allergic Rhinitis: This Rhinorrhea is recurrent with clear watery discharge as the patient reports (Dains, Baumann, Scheibel, 2016). Seasonal allergies cause short intense bursts of triggering agents that result in nasal inflammation, swelling, and may cause headache with compliant of pressure (Dains, Baumann, Scheibel, 2016).
P.
This section is not required for the assignments in this course (NURS 6512)
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby
Dains, J. E., Baumann, L. C., Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Up-to-date. (2017). Retrieved October 24, 2017, from https://www.uptodate.com/contents/uncomplicated-acute-sinusitis-and-rhinosinusitis-in-adults-treatment?source=search_result&search=acute%20sinusitis&selectedTitle=1~140.
Up-to-date. (2017). Retrieved October 24, 2017, from. https://www.uptodate.com/contents/pathophysiology-clinical-manifestations-and-diagnosis-of-migraine-in-adults?source=search_result&search=migraine%20without%20aura&selectedTitle=1~150
Up-to-date. (2017). Retrieved October 24, 2017, from https://www.uptodate.com/contents/medication-overuse-headache-treatment-and-prognosis?source=search_result&search=medication%20rebound%20headache&selectedTitle=1~150
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