NR509 Week 6: Case Perry Soloman

NR509 Week 6 Case Perry Soloman

History Questions & Responses

HPI

• How severe is your nausea and/or vomiting?
  That’s hard to say. Everything seems pretty severe when I’m having one of my bad headaches.

• Does anything make your nausea and/or vomiting better or worse?
  Yeah, headaches… or the absence of headaches!

• What treatments have you had for your nausea and/or vomiting?
  Nothing.

PMH

• Can you tell me about any current or past medical problems you have had?
  The usual childhood stuff. I’ve had headaches for about 10 years. Otherwise, not much to tell.

• Have you had any significant traumatic injuries or accidents?
  No I have not. Never been knocked out or anything like that.

• Any previous medical, surgical or dental procedures?
  No, nothing other than a few fillings.

• Are you taking any prescription medications?
  Not right now.

• Are you taking any over-the-counter or herbal medications?
  Sometimes Benadryl for sleep around finals time. I take acetaminophen or ibuprofen for some of my headaches. I use them however the box says.

• Can you provide the dosage and frequency of each medication you are taking?
  I am not taking anything right now.

• When did you last take your medications?
  I don’t regularly take medications.

• Do you have any allergies?
  Not that I know of.

FH

• Tell me about the health of your grandparents, parents, and children.
  Well, first off, I don’t have any kids—or siblings, for that matter. I know nothing about my birth father, and my mom’s pretty healthy other than having headaches like mine for as far back as I can remember.

SH

• Have you fallen?
  No.

• Do you drink caffeinated beverages or eat chocolate?
  I like chocolate. It’s my only real vice I guess. Maybe I overdo it a bit.

• Do you now or have you ever smoked or chewed tobacco?
  Absolutely not.

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Headache-Specific History

HPI

• Does the pain in your head radiate someplace else? Where?
  No, it doesn’t move anywhere else. It just stays there behind my left eye.

• Do you have any awareness or warning symptoms before the headache begins?
  Often my vision in both eyes gets spotty before the headache comes on. I can still see—it’s kind of like zig-zaggy flashing lights. My eyes are otherwise okay. Not swollen or watery. But that’s pretty much it.

• Does your headache pulsate?
  They’re a throbbing-type sensation. Really unpleasant.

• How severe (1–10 scale) is your headache?
  Oh, it’s pretty unbearable. Starts at 2 or 3, then becomes 8 or 10. I can’t do anything when I have one. They can last up to 15 hours, which means the entire day is shot.

• Does the headache awaken you from sleep?
  No. Sleep helps, but sometimes I do wake up with one in the morning.

• Is this the worst headache of your life?
  Not right now. When they do happen, the pain does get pretty bad. They just stink.

• Does anything make your headache better or worse?
  Helps if I lie down in a dark quiet room and try to sleep it off. Light and noise make it worse.

• What treatments have you had for your headache?
  I haven’t been seen by a doctor. I use acetaminophen but by the time I take it, I can’t keep it down because I’m nauseated. Same with ibuprofen. They used to work but not anymore.

Symptom

• Do you have nausea and/or vomiting?
  Only with my bad headaches.

HPI

• When did your nausea and/or vomiting start?
  When I started to have worse and more frequent headaches.

• What are the events surrounding the start of your nausea and/or vomiting?
  The bad headaches.

• Does your nausea and/or vomiting come and go?
  Yeah, with the headaches.

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History Feedback

• HPI: How can I help you today?
  Having really bad headaches for a few months. No current headache but wanted it checked out.

• HPI: Do you have other symptoms or concerns?
  Nausea, vomiting. Nothing else.

• HPI: When did your headache start?
  Worsened over last few months.

• HPI: Events surrounding the headache?
  In past, less frequent, felt like hat from hell strapped to head. Might correlate with stress.

• HPI: How long does it last?
  Sometimes lasts whole day (15 hours).

• HPI: Does it come and go?
  Yes, not constant.

• Symptom: New headaches?
  Yes, worse and more frequent in last months (every 1–2 weeks vs. every 1–2 months before).

• HPI: Any changes since it began?
  Only in frequency.

• HPI: Where is the pain?
  Pretty much left behind my eye.

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Plan Feedback

Pharmacologic Care

• Naproxen 500 mg once.

• Sumatriptan 50 mg once (may repeat after 2 hrs; max 200 mg/24 hrs).

• Metoclopramide 10 mg PO q6–8h for nausea/vomiting (max 45 mg daily).

• Neurology referral for preventative care.

Supportive Care

• Maintain hydration (3.7 L/day men, 2.7 L/day women).

• Trigger avoidance: limit red wine, chocolate, junk food.

• Stress reduction: moderate–vigorous activity 30–50 min, 3–5 days/week.

• Adequate sleep (8 hrs), avoid screens 2 hrs before bed.

• Reduce caffeine.

Patient Education

• Diagnosis: migraine; explained treatment, side effects, red flags.

• Education on medication-overuse headaches.

• Keep a headache diary (patterns, triggers, meds).

• Daily self-care, importance of follow-up.

• Preventive treatments if abortive ineffective.

• Red flag symptoms: thunderclap headache, fever + neck stiffness, uncontrollable vomiting.

Follow-Up

• Clinic f/u in 6–8 weeks to assess efficacy.

• Sooner if persistent/worsening migraines.

• ER if thunderclap headache, worst of life, severe pain, uncontrollable vomiting, neck stiffness/fever.