Question

History of Present Illness

A 49 y.o. woman, accompanied by her husband, comes into the primary care clinic complaining of a significant headache since that morning. Patient describes the headache as 8/10 and states that it started suddenly this morning after she attended a breakfast at the garden club. While she was sitting at the table, she felt an urge to have a BM, went to the bathroom, and returned to the table. Shortly after that, her HA started. She states she felt nauseous, but there was no vomiting. She drove home and tried to lie down.

Past Medical/Surgical History

Remarkable for two normal pregnancies with uncomplicated deliveries

Denies any prior surgeries

Current Meds

Nasacort and Allegra for seasonal allergies

Paxil for menopause symptoms

Ca+ and Vitamin D

Family History

Noncontributory

Psychosocial History

Denies illicit drug use, tobacco use; occasional ETOH consumption.

Physical Examination

General: Patient appears uncomfortable due to HA, but not in acute distress.

Vital Signs: BP 150/80 (high for her), HR 78, RR 20

HEENT: Head normal on inspection, without any areas of tenderness. Ears, nose, and throat clear. Pupils both small at 2 mm but reactive to light. Symmetrical extra-ocular movements and no nystagmus. Slight photophobia. Fundi and optic discs appear normal. No masses detected on examination of neck, no carotid bruits. Mild nuchal rigidity.

CV: Heart RR&R.

Abdomen soft and non-tender.

Respiratory: Lungs clear to auscultation bilaterally and normal respiratory effort.

Neuro: Patient fully alert, oriented, and calm. CNs intact. Motor strength symmetrical, with brisk and symmetric deep tendon reflexes without clonus. Cerebellar function and sensory systems normal.

Case Study Discussion – Part I:

Identify three conditions that you would consider in your differential diagnosis, with the most likely condition listed first. Provide rationale for each differential with supporting evidence from the case study.

What further history should be considered in order to explore your differential diagnosis and confirm your suspicions?

Answer 1

Differential diagnosis of a headache:

1. Constipation:

Constipation is defined as when there are less than three bowel movements in a week. Passing of hard stools causes strain and results in a headache. The gastrointestinal symptoms such as celiac disease, irritable bowel syndrome may also cause a headache. As the patient experienced a headache, immediately after Bowel movement and also the symptoms of nausea shows the evidence of gastrointestinal problems.

2. Meningitis:

Meningitis is the inflammation of the meninges that surround the brain and spinal cord. It shows the symptoms of nausea, headache, fever, stiffness. It requires immediate medical attention and treatment. The adults are most commonly affected with viral meningitis which she shows the possible symptoms of a headache, photophobia, and nuchal rigidity. Usually, a patient with corticosteroids and low immune system have a higher risk of meningitis.

3. A drug-induced headache:

She had a history of seasonal allergens and she is under Nasacort. Sometimes medication can cause side effects on the patient. Nasacort is a corticosteroid and too much of this medication may cause side effects of a headache. She also shows the history of ETOH consumption and illicit drug user.

Further history needed to confirm the diagnosis:

• A detailed history of a headache whether is new onset or old one. The frequency, duration, and pattern of a headache.
• History of her bowel pattern, hydration, and dietary habits and whether she includes high fiber diets to detect gastrointestinal function and problems.
• History of occupation, stress level at work to know a stress-induced headache.
• History of her sleeping pattern where the lack of sleep also causes a headache.
• Previous history any head injuries.
• History of withdrawal from any substances as she is an illicit drug user.
• History of dose and way of administration of Nasacort.