NR 576: Switi Patel on Case Amanda Wheaton

01 January 0001

Response to History Notecard by Switi Patel on Case Amanda Wheaton

History Notecard Summary:

Key Symptoms Identified:

  1. Headache - Patient’s main reason for the encounter.
  2. Additional Symptoms - Nausea, dizziness, sensitivity to light (photophobia).

Characterization of Symptoms Using OLDCARTS:

Symptom (Sx)OnsetLocationDurationCharacteristicsAggravating FactorsRelieving FactorsTimingSeverityHeadache3 weeks agoFrontal areaContinuousThrobbing pain, worsens with movementBright lights, noiseRest, dark roomConstant8/10Nausea2 weeks agoGeneralizedIntermittentAccompanied by headacheEatingRestOccasional5/10Dizziness2 weeks agoGeneralizedIntermittentSpinning sensation, worse with movementSudden movementsRest, lying downOccasional6/10Photophobia3 weeks agoEyesContinuousSensitivity to light, worsens headacheBright lightsDark roomConstant7/10

Potential Diagnoses and Considerations:

Patient Details:

  • Age: Consider the patient’s age.
  • Risk Factors: Relevant medical history, lifestyle, and environmental factors.
  1. Migraine:
    • Symptoms: Headache, nausea, photophobia, dizziness.
    • Characteristics: Throbbing pain, sensitivity to light, worsens with movement.
    • Risk Factors: Family history of migraines, stress, certain foods or drinks.
  2. Tension Headache:
    • Symptoms: Headache, possibly associated with nausea and dizziness.
    • Characteristics: Pressure or tightness around the forehead or back of the head and neck.
    • Risk Factors: Stress, poor posture, eye strain.
  3. Sinusitis:
    • Symptoms: Headache, nausea, dizziness, possibly photophobia.
    • Characteristics: Pressure or pain in the sinuses, worsens with head movement.
    • Risk Factors: Recent upper respiratory infections, allergies.
  4. Vestibular Migraine:
    • Symptoms: Headache, dizziness, nausea, photophobia.
    • Characteristics: Vertigo or balance disturbances, often without a visual aura.
    • Risk Factors: Family history of migraines, stress.
  5. Cluster Headache:
    • Symptoms: Severe headache, photophobia, nausea.
    • Characteristics: Sudden onset of intense pain around one eye, occurring in clusters.
    • Risk Factors: Smoking, alcohol consumption.

Plan for Physical Examination:

  • Focus Areas: Neurological examination, assessment of head and neck, check for signs of sinusitis, eye examination for photophobia.
  • Additional Tests: Consider MRI or CT scan of the head, sinus X-ray, vestibular function tests.

Next Steps:

  • Conduct a thorough physical examination based on the identified symptoms.
  • Order appropriate diagnostic tests to confirm the underlying condition.
  • Develop a treatment plan focusing on symptom relief and addressing the root cause.

Management Plan:

  • For migraines: Prescribe appropriate medication (e.g., triptans), recommend lifestyle modifications to avoid triggers, consider preventive medication if migraines are frequent.
  • For tension headaches: Suggest stress management techniques, ergonomic adjustments, over-the-counter pain relief.
  • For sinusitis: Prescribe antibiotics if bacterial infection is suspected, recommend nasal decongestants and saline irrigation.

This structured approach will aid in organizing symptoms, correlating them with potential diagnoses, and planning the next steps for physical examination and diagnostic testing.