Question

Patient Name: Jennifer Markus                                                                                                                                   MR#: 45879

Attending Physician: Katrina McKenzie, M.D.

Consulting Physician: Erik Anderson, M.D.                                                                                                            Date: 12/4/11

Subjective: Mrs. Markus is a 33-year-old woman with a PMH [past medical history] significant for depression, asthma, hiatal hernia, and migraine headaches. She presents complaining of waking with a pulsing headache on the left side of her head, with 1 day of prior increased sensitivity to light and to noises, as well as nausea, no emesis. The patient notes that work has been increasingly stressful over the past couple weeks and she’s had trouble sleeping. She took two tablets of ibuprofen last night in the hopes of avoiding a migraine, with minimal relief. She is currently taking sertraline for her depression.

She denies any history of seizure, cluster headaches, or tension headaches. She does smoke approximately one half pack of cigarettes daily. She notes that she’s been getting these headaches more frequently, as in two to three times per month. She would like something to decrease the duration of the headache, as well as some suggestions for prevention of future headaches.

Objective: VS: BP 134/80, HR 76, Temp 98.4, wt 155. Physical Exam. General: The patient is sitting with her eyes partially covered by her hands, otherwise, no acute distress. HEENT: Normocephalic/atraumatic, conjunctivae noninjected, pupils equal and round, reactive to light and accommodation (PERRLA), ears with normal cone of light reflex, nose with clear discharge, throat nonerythematous. Neck: No lymphadenopathy, thyroid smooth and symmetric, no nodularity palpated. Lungs: Clear to auscultation bilaterally. Heart: Regular rate and rhythm, no murmurs/grunts/rubs. Abdomen: Soft, nontender, nondistended, no abdominal bruits. Extremities: Warm and well perfused at distal extremities, no edema bilaterally. Musculoskeletal (MSK): Strength of upper and lower extremities equal and 5/5, no loss of sensation at extremities, normal patellar reflexes bilaterally.

Assessment: Patient is a 33 yo female with symptoms and physical exam consistent with migraine headache.

Plan: Migraine Headache Treatment. Begin the patient on a combination treatment of sumitriptan 85 mg and naproxen 500 mg, daily, for the duration of the headache.

Prevention: Continue with the sertraline, as it can have protective effects. Begin a smoking cessation regimen, because smoking can worsen headaches. Recommend some manner of stress-reduction practice, whether it be regular exercise, meditation practice, or relaxation practice.

Follow-up in 3 weeks to evaluate progress and number of headaches. At that time, will reevaluate with the possibility of adding a beta-blocker or calcium channel blocker. Patient was advised that if this headache worsens or fails to improve in the next 24–48 hours, she should call the clinic.

Erik Anderson, M.D.

Discussion Questions

3.     Why did the doctor ask whether Ms. Markus had a history of seizures?

4.     Dr. Anderson suggests that the patient continue with sertraline, which she is taking to counteract the effects of depression. What is the definition of depression

Answer 1

Seizures

                      A seizure is a sudden, uncontrolled electrical disturbance in the brain. It can cause changes in the behavior, movements or feelings, and in levels of consciousness.

                 Headaches may occur before seizures and are common after tonic-clonic seizures. In rare cases, the brain wave changes seen on the EEG show that a headache can actually be the only symptom of a seizure. These headaches usually last between about 6 and 24 hours, or sometimes even longer.

           In patients with seizure aura have symptoms such as:

• Visual aura
• Irritability
• Nausea/vomiting
• Sensitivity to light and sound

Here the Patient is presented with complaints of Sensitivity to light and noises and Nausea which are the symptoms of seizures. That’s why the Doctor asked the patient whether she had any past history of Seizures.

Depression

               Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest. Also called major depressive disorder or clinical depression, it affects how feel, think and behave and can lead to a variety of emotional and physical problems.