Physical Examation Of Patient With Headaches Problem

Physical Examation Of Patient With Headaches Problem

GENERAL INFORMATION

Patient Name: Mr. R., 24 years old Name/Initials of Examiner: I.W

Gender: Male Source of Referral: Self-referral

Source of History/Reliability: Patient himself Date: 07/14/2022

PROBLEM LIST

Shortsightedness

CHIEF COMPLAINT (CC): “My head aches”

HISTORY OF PRESENT ILLNESS (HPI):

For about four months, Mr. R has had increasing problems with headaches on one side of the head. He associates his headache with nausea and vomiting hence missing classes on several occasions. Regarding the timing, Mr. R reports that headaches average once a week and last for three to five hours. His headaches are related to increased stress experienced when at school or in other settings. Notably, the headache is relieved by sleeping with a woolen pillow under the head and aggravated by loud sounds, sleep changes, missing sleep, and too much sleep and sleeping on a hard pillow. Mr. R experiences a little relief from acetaminophen (Tylenol). The headaches are associated with visual modifications whereby “visual distortion” last approximately 10 to 15 minutes. However, there is no associated constant pain in sinuses and cheekbones, motor sensory deficits, or paresthesia Physical Examation Of Patient With Headaches Problem.

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Headaches associated with nausea, vomiting, and visual modifications began at 20, recurred when he was 23, and then depreciated to two episodes every three or four months and almost disappeared. Mr. R reports that the problem recurred four months ago and thinks that his headache is similar to those of the past but is concerned that they will interfere with his studies and work. He reports increased stress and pressure at college and in the workplace where he works as a part-time waiter.

PAST MEDICAL HISTORY (PMH):

PAST CHILDHOOD ILLNESSES: He had measles at age of 5, which was effectively treated, and did not experience relapse. Mr. R had mumps at the age of 7 that was also treated without complications.

Accidents & Injuries: None

Serious or Chronic Illness: None

Hospitalizations: None

PAST SURGICAL HISTORY (PSH): None

ALLERGIES: Mr. R has no known food, drug, and environmental allergies

Medications: Mr. R uses over-the-counter Tynelol (antipyretic and analgesic) 500mg PRN to help relieve headache

UNTOWARD MEDICATION REACTIONS: None

IMMUNIZATION STATUS:

Mr. R reports that he received immunization for hepatitis A, hepatitis B, diphtheria, tetanus, and acellular pertussis during his childhood. He also states that he received the following immunization in his childhood; inactivated poliovirus inactivated influenza, measles, mumps, rubella, and varicella as recommended. During his adolescence, he received tetanus, diphtheria, and acellular pertussis. Currently, Mr. R adheres to the recommended annual influenza vaccination and has received his due jab for this year Physical Examation Of Patient With Headaches Problem.

SCREENING TESTS:

Blood pressure, 2021, 130/86mmHg, pre-hypertension (not within the normal range of 90/60mmHg and 120/80mmHg)
Cholesterol screening, 2022, negative for hypercholesterolemia
Diabetes, 2022, BMI 23.9, random blood glucose level 6.1mmol/L
Eye exam, four months ago, no abnormalities were detected
Dental examination, 2021, No abnormities

FAMILY HISTORY:

Father is hypertensive diagnosed at 43, well controlled on medications
Mother is hypertensive and has a stroke, on medications, physiotherapy, and doing well
The elder brother has diabetes mellitus, diagnosed at 35
His elder sister has recurrent migraine diagnosed at 26
His paternal grandfather was known hypertensive diagnosed in his adulthood and died of the same condition at 78 years
Paternal grandmother had coronary heart disease diagnosed at 56, died of unknown cause at 67
Maternal grandfather had asthma diagnosed in childhood. The patient is unsure about the cause of the death of his maternal grandfather.
Maternal grandmother died of heart disease diagnosed in adulthood and died of cardiac failure Physical Examation Of Patient With Headaches Problem

Obstetric/Gynecologic: Not applicable

PERSONAL/SOCIAL HISTORY:

Mr. R is a 24-year-old heterosexual African-American male who is single and lives with his parents in Marietta, Georgia. He currently works as a part-time waiter in a restaurant and studies at a nearby college where he takes a food science and nutrition course. Mr. R exercises often where he is outside his job and classroom. His common exercises are sports and Yoga. He states that he does not consume alcohol, use tobacco, or abuse any recreational or prescribed drug. Mr. R states that he uses coffee daily. Regarding his nutrition history, Mr. R states that he prefers meals with more vegetables and dislikes wheat. However, he reports that he occasionally feeds on junk foods from stores, restaurants, or other food outlets. Mr. R denies using assistive devices to walk around. He also states that he can perfume activities of daily living comfortably without needing help. However, occasional cases of headache flare-ups disrupt his performance of ADLs and involvement in classroom learning. Mr. R notes headaches and significant hurdles, which occasionally challenge his job and studies.

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SEXUAL HISTORY:

He is sexually active and has plans to use condoms during sexual activities with his girlfriend. He denies promiscuity and multiple sex partners. His last HIV/AIDS and STIs testing occurred three months ago (both negative)Physical Examation Of Patient With Headaches Problem.

Review of Systems:

General: Normal weight male, cheerful; denies fatigue, fever, or chills. The patient has gained weight and he is not sure about pounds lost, recent weight gain or loss, and alteration in appetite. Negative for lethargy and easy fatigability

Skin: Negative for bruises, rashes, itchiness, primary lessons, secondary lesions, hair thinning and

HEENT

Head: Has headache, negative for dizziness and head injuries

Eyes: Experiences blurred vision associated with episodes of headache, no visual loss, does not wear contact lenses, not eyeglasses. No history of trauma to the eyes, glaucoma, or cataracts

Ears: No hearing loss, otalgia, tinnitus, discharge

Nose: Does not sneeze, no nasal congestion, rhinorrhea, epistaxis

Throat: No sore throat

Breasts: No lumps, tenderness

Respiratory: Negative for coughing, shortness of breath, dyspnea. No cyanosis

Cardiovascular: No history of cardiovascular illness, no hyperlipidemia, palpitations,

Gastrointestinal: Has nausea and vomiting. No diarrhea, or constipation. No anorexia, abdominal pain, stool inconsistency, or blood in stool

Genitourinary: No difficulty micturition, hesitation while voiding bladder, nocturia. No painful urination or burning sensation

Peripheral Vascular: Denies history of edema on lower extremities, tender fingertips, and cold extremities in cold weather, varicose veins, and deep vein thrombosis.

Musculoskeletal: No back pains or pain in other body parts.

Neurologic: Experiences headache. No dizziness, paralysis, or syncope. No dull or sharp pain on other body parts.

Hematologic: No anemia, easy bruising, or bleeding

Endocrine: No cold or heat intolerance, Denies known thyroid or blood glucose problems, negative for polyuria, polydipsia, and polyphagia

Psychiatric: No history of anxiety, depression, or suicidal ideation

DIFFERENTIAL DIAGNOSES

Hypertension
Migraine
Hyperthyroidism

LAB DATA/TESTS :

CBC – hemoglobin 13.2g/dL (normal being 13.2 to 16.6g/dL)

Hematocrit 40.6% (normal being 38.3 to 48.6%)

TSH- 3.0Miu/L (normal being 0.5 to 5.0 mIU/L)

Cholesterol – total cholesterol 193mg/dL (normal below 200mg/dL) Physical Examation Of Patient With Headaches Problem

PHYSICAL EXAM

Vital Signs: Blood Pressure- 142/94mmHg (elevated), P- 98bpm RR- 36 cycles/min T- 98.9^oF, Height- 5.9 feet, Weight- 166.7lbs, BMI- 23.9

General: No signs of obvious distress

Skin: Warm and moist with no lesions, sores, or cracks

HEENT:

Head: Normocephalic, No signs of trauma

Eyes: pink conjunctiva, the sclera is white, no discharge. Shortsightedness

Ears: Warm to touch, no tenderness, discharge, otalgia

Nose: Pink and moist nasal mucosal with a nasal septum at the midline that is not deviated or traumatized

Throat: No sore throat, oral mucosa is moist, pink without lesions or sores

Neck: The jugular veins are palpable, no distension, lumps, or scars

Breasts: Breasts are symmetrical in position and size. No tenderness, discharge

Lymphatics: non-tender lymph nodes such as superficial cervical and mammary

Lungs: Symmetrical chest movement with respiration. On auscultation, the chest is bilaterally clear. No cough, wheezing

Heart: Has a regular heart rate with no murmurs, added sounds

Abdomen: No scars, protrusions, or lesions. Bowel sounds were heard on auscultation. The abdomen produces a tympanic sound on percussion. A dull sound was noted over the abdominal organs. No tenderness or obvious organomegaly on palpation

Genitourinary: No dysuria, Genital exam not done. The normal genital exam would reveal external genitalia that lacks sores, obvious edema, or distended testis. Testes would be descended bilaterally without tenderness. The penis would have no lesions, sores, and discharge from the urethra while the scrotum would lack erythema and edema. No inguinal hernia noted Physical Examation Of Patient With Headaches Problem

Rectal: Rectal exam not done. A normal exam would be a rectal vault that lacks masses, hemorrhoids, sores, fissures

Peripheral Vascular: Capillary refill takes 2-3 seconds. Peripheral pulses present bilaterally on radial, tibial, popliteal, and femoral. No changes in pigmentation, erythema, or cyanosis. No edema o lower extremities, coldness in cold weather. The Upper and lower extremities are warm bilaterally.

Extremities: Musculoskeletal: Lower extremities – lacks joint deformities, no crepitus on the knee joint, no knee pain or tenderness. Equal ROM bilaterally for, hips, ankles, and shoulders Spine is negative for kyphosis and lordosis.

Upper extremities – no deformities, bilaterally equal ROM for wrists, elbows

Neurological: Alert

Mental Status: oriented to person, place, time, and situation

Cranial Nerves: cranial nerves I to XII intact

Motor: upper and lower strength 5/5 bilaterally in both upper and lower extremities.

Cerebellar: gait and balance, heel to the shin, pronator drift, rapid alternating action, finger-to-nose movements, and coordination are all intact. Has balanced gait, stable, and lacks ataxia.

Sensory: Pinpricks, touch on the palm, graphesthesia, vibration, and stereognosis are intact.

Reflexes: Deep tendon reflexes present and symmetrical at the patellar, Achilles, plantar downward, biceps, and triceps.

Psychiatric: Alert, oriented to place, time, person, and situation. More assessment not done; Normal finings would include intact memory, coherent thought process, congruent mood and affect, and good judgment Physical Examation Of Patient With Headaches Problem

DIFFERENTIAL DIAGNOSES:

Hypertension

Hypertension, or high blood pressure, is a condition in which the force of the blood against the walls of the arteries is too high. This increased force can damage the arteries, and over time can lead to heart disease, stroke, and other serious medical conditions. Many factors can contribute to hypertension, including genetics, age, lifestyle choices (such as smoking), and the presence of major diseases such as heart attack or stroke. Other factors that can contribute to headaches include obesity, excessive drinking, strong caffeine consumption, and stress. However, the primary cause of hypertension is an increase in blood pressure caused by a combination of high blood volume and high blood pressure. This increased fluidity within the blood vessels causes them to become more prone to swelling and rupture.

Migraine

Migraine is a common and disabling condition that is characterized by recurrent attacks of severe headaches (Ruschel & De Jesus, 2020). The pathophysiology of migraine is complex and is thought to involve interactions between the brain, blood vessels, and muscles. The cause of migraine is unknown, but it appears to be related to a combination of genetic and environmental factors. Migraineurs often experience a variety of other symptoms such as sensitivity to light and sound, nausea and vomiting, diarrhea, fatigue, and mood changes.

Hyperthyroidism

Hyperthyroidism, or overactive thyroid, is a condition in which the thyroid gland is overactive, leading to an increase in the production of hormones that can lead to problems such as weight gain, heart disease, and increased rates of cancer. (Doubleday & Sippel, 2020)Physical Examation Of Patient With Headaches Problem. This hormone regulates the body’s metabolism, so an overabundance can cause several serious problems. The pressure and inflammation that are hallmark features of this condition can cause intense pain in the head, neck, and temples. One of the most common symptoms of hyperthyroidism is a headache. In some cases, the headaches may be so severe that they interfere with daily life. Hyperthyroidism also can lead to other health problems, including weight gain, heart disease, and infertility. If left untreated, hyperthyroidism can even lead to death.

Hyperthyroidism is one of the differential diagnoses for Mr. R with a headache because it can cause an increase in blood pressure and heart rate, which can lead to a headache. Headache is one of the most common symptoms of hyperthyroidism, and it can be caused by a variety of factors including anxiety, stress, pain from headache medications, and neck or jaw tension. Hyperthyroidism can also cause changes in mood such as irritability and restless behavior. However, Mr. R did not report or present with mood changes and irritability.

ASSESSMENT

A 24-year-old male with a primary medical history of recurrent headaches presents to the clinic complaining that his “headaches.” He has born with the problem four months ago when the problem recurred following several headache attacks at his 20^th and 23^rd ages. The patient states that headaches are associated with nausea, vomiting, and blurred vision. Visual distortion associated with the headache takes 10 to 15 minutes. The major symptoms- headache, last for three to five hours and allow experience a little relief when he uses acetaminophen 500mg TDS. He had a previous blood pressure measurement earlier this year which showed that he had pre-hypertension. He has not used any other medications Physical Examation Of Patient With Headaches Problem.

PLAN:

The working diagnoses for Mr. R are hypertension and migraine

Hypertension

The patient’s blood pressure is elevated
Need to obtain blood pressure measurements outside of the clinical setting for diagnostic confirmation before starting treatment
If hypertensive, start propranolol 40 mg BD for two weeks, then review the progress (Srinivasan, 2019)
Advise patient to take medication as instructed
Patient to monitor pulse rate; notify care provider if HR is below 50bpm
Advise patients about side effects hence avoid driving or other activities, which require alertness
Repeat BP measurement on alternate days after today
Health education to engage in aerobic physical exercises and other measures to lose weight
Lifestyle changes to promote health in hypertensive patients- reduction in salt intake.
Continue avoiding the consumption of alcohol and smoking Physical Examation Of Patient With Headaches Problem

Migraine

Antihypertensive therapy to help alleviate migraine (Srinivasan, 2019)
Add P.O Sumatriptan 25mg BD initially (Ruschel & De Jesus, 2020)
Increase P.O Sumatriptan to 50mg BD if the response is inadequate
Advise patient to use Sumatriptan during migraine as a relief and not prevention
Advise patient to avoid sharp lights when experiencing migraine; rest in a darkened room
Education on medication side effects- chest tightness, wheezing, flushing, drowsiness; notify the care provider
Advice the patient to avoid alcohol which may aggravate headache

DIAGNOSTIC/CLINICAL REASONING EXERCISE

Mr. R presents with health that recurred four months ago. The problem is recurrent since when he was 21 years old. His pre-hypertensive state noted earlier this year demonstrated the need to adhere to preventive measures including a change of lifestyle to prevent the development of hypertension. Hypertension is one of the working diagnoses for Mr. R who has a headache as the major symptom. Headaches can be caused by several underlying conditions, so it is important to rule out any potential causes that may be specific to Mr. R. One of potential the causes of headaches specific to Mr. R. is hypertension. According to Wang, Tan & Han (2021), patients with hypertension demonstrated a negative association between headache and systolic blood pressure (SBP) and pulse pressure (PP). Considering the blood pressure measurement for Mr. R, his systolic blood pressure is elevated and may be congruent with the findings of Wang et al. (2021) who related SBP and PP with a headache. Hypertension can cause headaches by increasing the pressure in the blood vessels near the brain. The pathophysiology of hypertension is closely linked to the development of headaches. Headache is a common symptom of many medical conditions and is usually associated with pain located in one or more areas of the head. In most cases, the pain is caused by pressure on blood vessels near the brain. Hypertension can cause an increase in blood pressure that presses on these blood vessels, leading to headaches Physical Examation Of Patient With Headaches Problem.

Considering the recurrence of the headache and the associated symptoms of nausea, vomiting, and blurring of vision, it is likely that Mr. R has a migraine. Migraine is one of the working diagnoses for Mr. R who presents with headaches since when he was 21 years old. One of the reasons why migraine is one of the differential diagnoses for the patient is that it is a more severe form of headache (Ruschel & De Jesus, 2020). Second, migraine is a disorder that is associated with changes in brain function presenting with specific symptoms that are unique to it, such as visual disturbances and nausea. The recurrence on one side of the head for the last three years, severity and associated symptoms present in Mr. R confirm the diagnosis of migraine.

Health Maintenance:

Health maintenance for Mr. R as recommended by the USPSTF screening guidelines https://epss.ahrq.gov/PDA/index.jsp)

Specific Recommendations

The USPSTF recommends screening for hypertension in adults 18 years or older with office blood pressure measurement (OBPM).
Clinicians to screen for HIV infection in adolescents and adults aged 15 to 65 years
screening for syphilis infection in persons who are at increased risk for infection
clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions
screening for hepatitis B virus (HBV) infection in adolescents and adults at increased risk for infection
screening for hepatitis C virus (HCV) infection in adults aged 18 to 79 years
Latent tuberculosis infection (LTBI) screening
behavioral counseling for all sexually active adolescents and for adults who are at increased risk for sexually transmitted infections (STIs)Physical Examation Of Patient With Headaches Problem
screening for drug abuse by asking questions about unhealthy drug use in adults aged 18 years or older
screening for Unhealthy alcohol use in primary care settings in adults 18 years or older
counseling young adults, adolescents, children, and parents of young children about minimizing exposure to ultraviolet (UV) radiation for persons aged 6 months to 24 years with fair skin types to reduce their risk of skin cancer
behavioral counseling on a healthy diet and physical activity for adults without obesity who do not have hypertension, dyslipidemia, abnormal blood glucose levels, or diabetes

RTC:

The plan of care from Mr. R will also include follow-up. Mr. R with hypertension and migraine must keep track of his follow-up appointments and return to the clinic for regular check-ups. This will help ensure that the patient is receiving the best possible care and that any problems with their hypertension or migraine are identified and corrected as soon as possible. Mr. R will follow a return-to clinic appointment schedule that includes an initial check-up within two weeks of returning, then follow-ups at four-week intervals, then every six months. If there are any changes in the patient’s condition after appointments, such as an increase in their blood pressure or migraine headaches, he will contact the health care providers immediately to ensure prompt review and management.

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References

Doubleday, A. R., & Sippel, R. S. (2020). Hyperthyroidism. Gland surgery, 9(1), 124–135. https://doi.org/10.21037/gs.2019.11.01

Ruschel, P., & De Jesus, O. (2020). Migraine Headache. Treasure Island (FL): StatPearls Publishing/ https://www.ncbi.nlm.nih.gov/books/NBK560787/

Srinivasan A. V. (2019). Propranolol: A 50-Year Historical Perspective. Annals of Indian Academy of Neurology, 22(1), 21–26. https://doi.org/10.4103/aian.AIAN_201_18

Wang, L., Tan, H. P., & Han, R. (2021). The Association Between Blood Pressure and Headache in Postmenopausal Women: A Prospective Hospital-Based Study. International journal of general medicine, 14, 2563–2568. https://doi.org/10.2147/IJGM.S317780 Physical Examation Of Patient With Headaches Problem