Subjective Findings and Questions
In this case study, Sally is a 45-year-old female patient with a chief complaint of a headache that has been lasting during the last 30 days. The main subjective findings of the condition include a generalized and bilateral headache that is localized around the neck and the back of the patient’s head when she is at work. To clarify the situation and diagnose, additional questions about her family history, past surgeries, her style of life and habits, and a menstrual cycle should be asked.
Physical Assessment
One of the main tasks of a medical worker is to examine a patient, presenting with a headache as a chief complaint. This process includes a general survey, vital signs, focused head and neck assessment (scalp for tenderness and swelling and arteries palpation), and a full neurologic examination (extra-ocular movements) (Guilbeau & Lenahan, 2015). The search for some signs of infection, fever, seizures, or behavioral changes helps to define red flags and deal with suspicions (Lee, Ang, Soon, Ong, & Loh, 2018). Brain and nerves condition should be evaluated for physical or structural abnormalities.
Diagnostic Studies and Tests
Several tests are necessary to diagnose and manage headaches in patients. A headache can be a physiological response to infection or some unknown trauma (May 2018). Therefore, blood chemistry and urinalysis will help to determine the conditions that cause headaches, if any. Technological advances like computer tomography, magnetic resonance imaging, or electroencephalogram are used to get clear pictures of the brain (Micieli & Kingston, 2019). A spinal tab aims at checking the condition of the brain/spinal cord if new suspicion occurs.
Differential Diagnosis
The list of differential diagnoses for Sally’s symptoms and headache complaint may vary, but the most serious alternatives are (Guilbeau & Lenahan, 2015):
- Migraines that include a bilateral headache symptom to worsen with time;
- Chronic daily headache that can be transformed into migraine or depression with medications as the main form of treatment;
- Tension headache that is hard to diagnose, but life modifications are obligatory.
Main Diagnosis
Regarding the chief complaint and the style of life of the 45-year-old female patient, the most likely diagnosis is a tension headache. Such symptoms as occipitofrontal location (head’s back and neck) and bilateral intensive pain at work can be caused by stressful events at work or muscular contractions (Guilbeau & Lenahan, 2015). Therefore, this condition may be both episodic and chronic due to its self-limiting nature.
Treatment
The necessity to manage stress in life and make some personal changes is the main non-pharmacological recommendation for the patient. Regarding Sally’s health beliefs and cultural preferences, homeopathic therapy is a good contribution to her health. Still, pharmacological therapy must be considered, including nonsteroidal anti-inflammatory (NSAIDs) and tricyclic drugs (May 2018). The possibility of side effects of these medications is minimal, and the patient should get the necessary explanations and lessons.
Pharmacological Intervention
Pharmacological interventions in acute and chronic pain usually vary because of the goals to be met in management. Essential care for acute headaches includes patient’s safety, well-being, and the prevention of other serious diseases (Cox, 2018). Compared to acute pain that may be gone in some period, chronic pain management should include medication prescription with tricyclic antidepressants and NSAIDs (Cox, 2018). The age factor may be critical in diagnosing headaches and the identification of causes. Still, the treatment plan for this disease should hardly be changed due to the age of the patient. Similar pharmacological and non-pharmacological changes have to be recommended in this case.
References
Cox, F. (2018). Advances in the pharmacological management of acute and chronic pain. Nursing Standard, 33(3), 37–42. Web.
Guilbeau, J. R., & Lenahan, C. M. (2015). Assessment, diagnosis, and management of headache. Women’s Health, 3(3), 43-46. Web.
Lee, V. M. E., Ang, L. L., Soon, D. T. L., Ong, J. J. Y., & Loh, V. W. K. (2018). The adult patient with headache. Singapore Medical Journal, 59(8), 399-406. Web.
May, A. (2018). Hints on diagnosing and treating headache. Deutsches Ärzteblatt International, 115(17), 299-308.
Micieli, A., & Kingston, W. (2019). An approach to identifying headache patients that require neuroimaging. Frontiers in Public Health, 7. Web.