Comprehensive Patient Assessment and Clinical Judgement - Case Study Example

Comprehensive Patient Assessment and Clinical Judgement Report Name Institution Comprehensive Patient Assessment and Clinical Judgement Report Part A: Comprehensive Assessment Patient’s Presenting Problem Pat Bellamy is a 49 year old woman who came to the Emergency Department (ED) using a taxi. She presents with severe and persistent headache that has lasted three days, gets worse with movement or exposure to too much light. Initial Observations Signs and Symptoms Temperature 38.1 degrees Celsius, HR 90, BP 156/80 Feeling nauseous and has vomited twice. Neck pain and stiffness. Affective/ Emotion Signs and Symptoms Well-groomed woman, alert, and anxious. Oriented to time and place. Came to the ED using a taxi Thought content: She says she is worried because her neighbour had severe headaches that got worse and she started experiencing seizures leading to a diagnosis of brain tumour. She is also concerned that she recently changed insurance companies and she is not sure if she can use her cover. Behavioural signs and symptoms: Responds to questions and instructions well considering her thought content and situation. Holds onto her head in a forward leaning posture to avoid too much light and moving her neck. Frequently grimaces with pain. Pain has made it difficult for her to go to work or engage in any other activities. History Medical and Surgical History Bloods pressure managed through dietary changes and goes for check-ups. No history of any other chronic illnesses. No known food or drug allergies. Not on any regular medications, recently took Tylenol 500mg X 2 and Motrin 200mg but did not relieve headache. No history of surgery. Psychiatric History No history of mental disturbance. Gynaecological/ Obstetric History LMP- She is in menopause. No history of deliveries. Drug and alcohol history Does not take alcohol. Smokes half a pack of cigarettes in a day. No recreational drug use. Family History All family members alive and healthy. Mother has a history of migraines. Father has a history of high blood pressure. No history of any other chronic illnesses. Current Social Support/ Circumstance She is married and the husband is away on a business trip returning tomorrow. She has no children. Part B: Case Study Report 1 a) What is Going on Here? Pat is a 49 year old woman working as a receptionist in a law firm. Pat comes to the emergency department by taxi presenting with a three day history of severe and persistent headache. Pat rates the pain as 10 stating that she feels it all over the frontal part of her head. She states that the headache started off as mild and gradually increased in intensity and once severe, it remained constant. She also reports that she feels nauseas and has vomited twice. Pat says that she is also experiencing a pain in her neck which also feels stiff. She is not on any regular medications and recently took Tylenol 500mg twice and Motrin 200mg but the medication did not relieve the pain. In her attempt to relieve the pain she took Tylenol and Motrin several times over the three days but the symptoms remained persistent. Pat has a recent history of travel to North Carolina about two weeks ago. She reports that during her visit to North Carolina, there was a sick four year old child; she does not know what the child was suffering from. Pat reports that the headache gets worse on movement or exposure to too much light and she tries to avoid moving about. Due to the pain, Pat is unable to go to work or do anything. Pat is anxious as a result of the severe headache stating that she has never experienced such pain before. Her concern is that her neighbour once had severe headaches and ignored them, the condition worsened and she started having seizures and later, the diagnosis was a brain tumour. She is also concerned that she just changed insurance companies and she is not sure if she can use her cover at the time. Pat seems stressed due to the pain she is experiencing and leans forward all through the assessment in a manner to avoid too much lights and movement as she also experiencing some pain on her neck. Her communication is consistent through marked with signs that she is struggling to deal with the pain and at the same time answer questions. On observation her blood pressure is high at 150/80 with the systolic indicating hypertension and the diastolic showing prehypertension, her heart rate is 90. She also has a fever of 38.1 degrees Celsius. Her physical presentation is neat as she is well dressed and her hair is neatly combed. Her mood and affect are consistent with the situation. She seems tensed owing to her concerns over the cause of the pain and her insurance. She holds on to her head as she talks and her facial expression is one indicating severe pain. Pat constantly states that she has never experienced such pain before. She does not make many movements during the conversation due to her stiff neck and aggravation of the headache on movement. There are several risk factors that are relevant to Pat’s signs and symptoms. Pat is presenting with a severe migraine headache. She reports that her mother had a history of migraines at the age of twenty to thirty years. Pat is also hypertensive and has managing the condition through dietary changes thus she has a cardiovascular risk. Pat also smokes half a pack of cigarettes in a day which adds to her cardiovascular risk. She recently travelled to North Carolina and that is a risk factor for experiencing the migraines due to changes in weather or barometric pressure. 1 b) Pathophysiology of Clinical Manifestation Pat presents with severe headache that has been persistent for the past three days, has no relieving factors even with the use of pain medication and gets worse on movement or exposure to too much light. The severe headache came about as a result of activation of the trigeminovascular system, cortical spreading depression and neuronal sensitization. According to IHS (2013), there are key structures playing a significant role in the activation of trigeminovascular system. Sensory neurons originating from the trigeminal ganglion and upper cervical dorsal roots stimulate the dural-vascular composition such as pia vessels, dura matter and cerebral vessels. Contribution from dural-vascular composition and cervical structures via the upper cervical dorsal root impel to second order neurons in the trigeminocervical complex. Nerve fibres implicated in the identification of pain rise from the trigeminal nucleus caudalis towards the thalamus and to the sensory cortex. Spreading of headache pain to the parts of the upper neck and head can then result from the junction of projections from the trigeminal nerve at the trigeminal nucleus caudalis as well as upper cervical nerve roots. Sensory inflection can take place, through both direct and indirect impulsion. The sensory modulation can be via downward stimuli including those from the hypothalamus, midbrain periaqueductal gray, nucleus raphe magnus and pontine locus coeruleus onto the trigeminocervical complex. Rising stimuli to the sensory inflection can also occur from the hypothalamus, locus coeruleus, and periaqueductal gray (Siva & Lamp, 2015). The Pathophysiology of the severe headache could also arise from cortical spreading depression. The term refers to a self-propelling wave of cellular depolarization that gradually extends across the cerebral cortex. The wave of cellular depolarization is linked to depressed neuronal bioelectrical action and modified brain function. The process leads to the stimulation of neurons in the trigeminal nucleus caudalis. As a result, there is an inflammatory alteration in pain-sensitive meningeal vascular regions thus generating a headache through central and peripheral reflex systems. According to IHS (2013), cortical spreading depression can also modify the permeability of the blood-brain barrier through activation and increasing of the response of the brain matrix metalloproteinase. Hence, due to the process, a headache arises. Neuronal sensitization is also another process that contributes to the Pathophysiology of severe headaches. Neuronal sensitization refers to the progression by which neurons become gradually more responsive to nociceptive and non-nociceptive stimulus (Goadsby, 2016). Sensitization leads to diminished response thresholds, intensified response magnitude, extension of receptive fields, and the occurrence of spontaneous neuronal action. Peripheral sensitization within the primary afferent neuron and central sensitization of higher-order neurons in the brain and spinal cord are significant in somatic pain. Therefore, as a result of sensitization, the patient experiences symptoms such as severe headaches and its aggravation by physical activity as well as exposure to light (IHS, 2013). Therefore as a result of neuronal sensitization, cortical spreading depression or activation of trigeminovascular system, a patient may experience severe headaches among other symptoms. The headache then proceeds in stages, it starts off as mild then intensifies to a level where it remains constant. The headache can be in the form of a severe throbbing pain or a pulsing sensation on either one side or a big region of the head, for example, the frontal part as in Pat’s case. The pain can last for hours to days and can be disabling (Steiner et al., 2015). Pat reports that she is unable to do anything, she cannot even go to work anymore. In understanding the Pathophysiology of the severe headaches, it is also essential to look at the stages through which the symptom intensifies into its persistent nature. A few days before the headache, the patient may experience slight alterations that could act as warning signs of an upcoming severe headache. Some of the signs include constipation, mood alterations, food cravings, neck stiffness, polydipsia, polyuria, and regular yawning. Some of the warning signs may proceed with the intensification of the headache such as stiff neck in Pat’s case. The warning signs can then lead to nervous system disturbances. For instance, visual difficulties such as photophobia, flashes of light or blurred vision. The patient may also experience sensory, motor, and verbal challenges before or during the time he or she has headaches. The patient then experiences severe headache that may last for four to slightly over seventy two hours if not treated. During the headaches one may have throbbing or pulsing pain on one or both sides of the head, light sensitivity, nausea and vomiting, blurred vision, and drowsiness (Pari et al., 2015). 2. What else do I need to Know? What further information is required from this point? In establishing the cause of the symptoms and coming up with the most effective therapy for management of Pat, it is necessary to get more information from the patient. It is essential to know Pat’s wake-sleep pattern. According to Almoznino and colleagues (2017), getting too much or inadequate sleep may trigger migraines. It is also important to establish the means that Pat used to travel to North Caroline. Siva and Lamp (2015) explain that severe headaches could occur as a result of jet lag. Additionally, it is essential to look into the patient’s psychological well-being. Assess to note if the client could be experiencing stress either at home or work as it could cause the headaches. At this point, it is essential to encourage Pat to open up about her work and life in general to enhance the identification of any stressors. Physical exertion can also lead to migraines (Steiner et al., 2015). Get to know more about the kind of activities that Pat takes part in on a normal day, particularly narrowing down to the past two weeks. Pat reports that she manages her hypertension through dietary changes. It is vital to explore the kind of foods that she takes. According to IHS (2013), foods such as salty meals, aged cheeses and processed products may set off migraines. Similarly, skipping meals or fasting can also generate severe headaches. Food additives such as aspartame and monosodium glutamate may also cause migraines. It is also important to get further information on medication use. Goadsby (2016) states that taking over the counter medicines frequently can lead to severe medication-overuse headaches. The headaches take place when the drugs stop relieving pain and start causing the symptoms instead. Therefore, considering Pat is hypertensive, it is essential to look into whether she could have experienced mild headaches and used over the counter medication. Additionally, it is important to ask whether Pat has undergone any hormone replacement therapy since hormonal changes are one of the causes of migraines. What other assessments/ investigations need to be performed or recommended in order to complete the clinical picture? For a complete clinical picture it is essential to do other investigations that can facilitate effective diagnosis and management of the patient. Conducting a blood test is essential to check for blood vessel complications, spinal cord or brain infections, and toxins in the systems. As mentioned in the Pathophysiology of severe headaches, alterations in the permeability of the blood brain barrier can lead to infections that trigger the inflammatory response indicated by severe headaches. The practitioner can also refer Past for a computerized tomography (CT) scan. A CT scan would be effective in ruling out tumours, infections, brain damage, internal bleeding or any other complications that could be causing the headaches. A lumbar puncture is also vital to aid in the diagnosis of underlying conditions. The test involves the analysis of cerebrospinal fluid for any signs of infection (Almoznino et al., 2017). Considering Pat is at cardiovascular risk due to her hypertension and the fact that she smokes cigarettes. It is essential to conduct an electrocardiogram test to establish any complications that need early interventions or underlying disorders. Pat also complains of neck pain implying the need to rule out cervicogenic headache. An X-ray can be effective in the diagnosis of cervicogenic headache to establish whether it could be the cause of movement difficulties that Pat reports she experiences. It is also essential to check for cranial or cervical muscle tenderness. A thorough neurological examination would help point out any other symptoms that aid in diagnosis and treatment of the condition (IHS, 2013). Another significant examination should be on scalp tenderness and if there is a reaction to non-painful stimuli. Use the Migraine Disability Assessment Scale (MIDAS) to establish the extent of impact of the condition on the patient’s ability to move around and independence in general (Siva & Lamp, 2015). Therefore, conducting the tests may be help to rule out differential diagnosis and guide treatment of the condition. What aspects of the patient’s health history need further information? There are various aspects of the health history that require additional information to enhance effective management of the patient. In the history of presenting illness there are several questions that need answers regarding the Pat’s condition. It is vital to get information on the nature of the headache that Pat is experiencing. Ask the patient whether the headache is throbbing, pulsing or hammering. According to IHS (2013), pulsating and throbbing headaches are common in migraines. It is also necessary to ask whether there are any other associating symptoms that come with the headache. According to Pari and colleagues (2015) vomiting can indicate migraine or intracranial disturbance while hypersensitivity for instance osmophobia or photophobia are signs of migraines. Autonomic characteristics such as lacrimation can be indicative of underlying disorders. Ask the patient whether her eye gets small, swollen or red. The features could be showing Horner’s syndrome. Limitation of activities is also an area that should be of consideration to aid in diagnosis and treatment (Steiner et al., 2015). It is essential to ask the patient whether the headache is just of one type or more. According to IHS (2013), migraine and cluster headaches can occur together especially in cases of trigeminal neuralgia or patients with sinusitis. When two types of headaches coexist, it is vital to recognize the condition as they will need separate treatments. In the patient’s past medical history, there is need to ask for experiences of fever and weight loss. If there is a positive history of fever and loss of weight, it could point to a systemic disorder. Also inquire on the history of galactorrhea that is essential in ruling out diagnoses such as hyperprolactinemia resulting from pituitary adenoma (Pari et al., 2015). Goadsby (2016) emphasizes that it is vital to ask the patient questions that would rule put immmunocompressed conditions such as HIV and cancers. It is also important to expand on the family history and user a genogram that could cover tree generations. According to IHS (2013), migraines are often a common familial tendency and there may be a strong positive indication of similar experiences among family members as well as other conditions that could coexist with the migraine. 3. What Does all This Mean? According to Siva and Lamp (2015), headaches can be spontaneous or due to an underlying cause. There are several types of headaches that point to the condition the patient is experiencing. In Pat’s case her symptom such as severe headache, nausea and vomiting, neck stiffness, and sensitivity to light point to migraines. The fact that she has a familial history of migraines from her mother also reinforces the diagnosis. IHS (2013) state that the causes of migraines are often related to genetic or environmental factors. Alterations in the brain stem and its association with trigeminal nerve may produce migraines. The Pathophysiology points to three main processes that contribute to the condition including activation of trigeminovascular system, cortical spreading depression, and neuronal sensitization. In diagnosing migraines a family history of the condition is a significant factor to consider. A neurologic examination, medical history, symptoms, and physical assessment will help to diagnose migraines. There is also a need to conduct several other tests to rule out the diagnosis. In Pat’s case, there is need to conduct a blood test to assess blood vessel complications, spinal cord or brain infections, and the presence of toxins that could be causing the severe headache and related symptoms. A CT scan is vital in checking for tumours, intracranial bleeding, infections or any other problems that could be generating the symptoms. A lumbar puncture would also allow for the analysis of spinal fluid for diagnosis of any infections. Therefore, for effective management of the condition it is essential to conduct various tests that would rule out differential diagnoses (Pari et al., 2015). According to Steiner and colleagues (2015), it is also essential to check for fever and weight loss in the patient that could indicate the presence of systemic infections. Pat should also be able to talk about her work and life in general to identify any stressors that could be causing the migraines. Considering she is anxious over the underlying cause of the headaches after a similar experience with her neighbour, it is critical to conduct thorough tests and reassure her. Once there is a clear establishment that Pat is suffering from migraines. The next step would be to effect treatment and management of the condition to increase her independence and ability to get back to work. It is also important to keep in mind that Pat is hypertensive and there is need for frequent monitoring of her blood pressure to institute measures that would keep her health in check. Smoking further increases Pat’s cardiovascular risk and it would be essential to advise her on the significance of quitting the habit for her well-being and refer her to a rehabilitative counsellor that would help her through the process. The treatment t process should begin with health education of the patient on the genetic predisposition to migraines. The information would help relieve the patient of her concerns. Considering the use of pain medication did not work, it may be necessary to use beta blockers that would not only manage Pat’s raised blood pressure but also diminish the frequency and severity of the headaches. Dietary considerations are also essential to avoid foods that produce migraines such as aged cheese, and additives like monosodium glutamate (Pari et al., 2015). Therefore, it is clear that Pat’s symptoms and history indicate that she is experiencing migraines. Since Pat is genetically predisposed to migraines, she may experience the headaches on other occasions. Hence, in the management of the patient the use of pharmacologic and non-pharmacologic techniques is essential. Pat can receive advice to try massage therapy or acupuncture that research has shown to be effective in relieving migraines (Almoznino et al., 2017). Lifestyle changes may also reduce the frequency and severity of the symptoms. She can ensure she gets enough sleep and also performs muscle relaxation exercises. Lastly advise Pat to keep a headache diary. In the journal, she can record incidences when she experiences the migraines and would help in identifying what triggers the headaches and as a result, manage it efficiently (Steiner et al., 2015). References Almoznino, G., Benoliel, R., Sharav, Y., & Haviv, Y. (2017). Sleep disorders and chronic craniofacial pain: Characteristics and management possibilities. Sleep medicine reviews, 33, 39-50. Goadsby, P. J. (2016). Bench to bedside advances in the 21st century for primary headache disorders: migraine treatments for migraine patients. Headache Classification Committee of the International Headache Society (IHS. (2013). The international classification of headache disorders, (beta version). Cephalagia, 33(9), 629-808. Pari, E., Rinaldi, F., Gipponi, S., Venturelli, E., Liberini, P., Rao, R., & Padovani, A. (2015). Management of headache disorders in the Emergency Department setting. Neuro Sci Off J Ital Neurol Soc Ital Soc Clin Neurophysiol. Siva, A., & Lampl, C. (Eds). (2015). Case-Based Diagnosis and Management of Headache Disorders. Springer International Publishing. Steiner, T. J., Birbeck, G. L., Jensen, R. H., Katsarava, Z., Stovner, L. J., & Martelleti, P. (2015). Headache disorders are third cause of disability worldwide. The journal of headache and pain, 16 (1), 1-3. Read More