The document shows a case presentation of a patient with a chronic headache

Case presentation family medicine

1. case presentation justice Uzira Kandjou mbbs iii

2. presentation outline Demographics Patient’s history Patient’s perspective Genogram Physical examination Differential diagnosis Investigations Four stage assessment

3. Demographics MR N. S M/39 SINGLE LIVES AT PARWE WARD MAHALAPYE WITH ONLY HIS FATHER FARMER (HORTICULTURE) BUT HE’S A DEGREE HOLDER

4. Patient’s history CC ; 3-month history of headache History of CC ; The patient reports he had previously been well until 3 months ago when he suddenly had a bilateral temporal headache of a severity of 6/10 with no history of head trauma. He reports that he went to the local clinic where he was given diclofenac, and he visited A&E two times. The patient reports the pain as a tight or pressure in character, he also reports that it radiates to the frontal region and to the occiput. He reports that the pain is alleviated by taking the painkillers that he was given usually when he’s going to bed. The headache is exacerbated by drinking alcohol and smoking, stress and shaking his head, he reports that after drinking alcohol he have bulging of the scalp veins and thus as well being more painful. The patient reports that the headache comes and go at least 5 times in a day, he explained the pain to start as pulsating for 5 seconds the gradually become pressure like which last for at least 5 minutes. He also reported that sometimes he wakes up to take the painkillers and go back to sleep. He also reports that the pain is associated with photophobia as well as a day history of stiffening neck.

5. Hx of cc cont … The patient reports no sensitivity to light or sound, nor any visual disturbances. The headache does not worsen with the consumption of foods known to trigger migraines, such as those high in tyramines or nitrates (like chocolate, coffee, or processed meats) or through physical exertion. There are no associated symptoms such as nausea, vomiting, neurological deficits, loss of consciousness, or aura. Additionally, the patient does not experience any prodromal symptoms such as excessive yawning, difficulty with writing, or sudden hunger. Also, the patient does not experience lacrimation (tear production), conjunctival injection (redness of the eyes), nasal congestion, or any nasal discharge. There are also no symptoms of eye drooping or changes in pupil size. The patient describes a dull, sharp pain located under the breast, accompanied by palpitations. The chest pain is not associated with any shortness of breath ( dyspnea ) or coughing and has been gradually improving over time

6. Hx of cc cont … On review of system CVS; no SOB, no peripheral leg swelling Resp; no coughing Abd; no abd pain, no constipation, no diarrhea Past medical history; RVD- ve last tested 3 months ago, no known illness Allergies; nil Surgical history; nil Family history; Nil for headache hx , no hx of malignancies, father is diabetic, mother is outside the country (Ireland)

7. Hx of cc cont … Social history; Degree holder; software engineering, now works as a farmer (horticulture), lives with his father with access to water and electricity in Parwe ward, he’s the only child, he is an alcoholic (almost every weekend) and smoke when he’s drunk, worried about his carrier and failing relationships. C- reports to have willing on cutting down alcohol A- does not reports any annoyance from people about his alcohol G- he feels guilty and regrets on how he uses his money E- does not report to take alcohol as an eye opener

8. perspectives R- headache I- thinking a lot, many internal thoughts C- no longer plays football E- get help to find permanent solution to his headache F- no complaint about her feelings F- fears that he might sometime fall on the pitch while playing football

9. genogram Lives outside Botswana (Ireland) Diabetic Male Female Patient Form 3, no known illness

10. examination On examination the patient was alert and communicating well in no obvious cardiorespiratory distress, no pain distress. J(-)A(-)C(-) C(-)O(-)L(-)D(-) Resp rate; 16 bpm BP; 140/79 mmHg Pulse; 66bpm SaO2; 97% on room air Temp; 36.0˚C

11. Cns exam Normal gait with GCS of 15/15, Pupils equal and reactive to light, no focal neurological deficit, normal tone at both lower and upper limbs and power of 5/5 in all the limbs. Cranial nerves intact. Normal muscle movements.

12. Respiratory exam I- no chest deformities, no scars, No use of accessory muscles P- symmetrical chest expansions, Normal tactile fremitus P - chest resonant to percussion A -Normal vocal fremitus, normal vesicular and bronchial sounds

13. Cvs examination Hands No stigmata of infective endocarditis(Janeway lesions, Osler’s node, splinter hemorrhage),radial pulses were palpable with good volume and normal rhythm. Warm peripheries Chest I -No visible scars and no other deformities on the chest No hyperactivity of the pericardium, no visible apex beat, no other visible pericardial pulsations P - No thrills palpable, No heaves. The apex beat was not displaced, it was in the fifthintercostal midclavicular space. A - There was normal heart sounds S1 and S2 on the mitral, tricuspid, aortic, and pulmonary valve areas, there were no murmurs heard.

14. Differential diagnoses Diagnosis For Against Tension headache Bilateral, triggered by stress, episodic, pressure like migraine Photophobia Unilateral, no nausea and vomiting, not triggered by foods with nitrates or tyramines, no visual disturbances Paroxysmal hemicrania Triggered by shaking head, duration and timing Unilateral, no ANS symptoms Cluster headache Can be triggered by alcohol unilateral, no ANS symptoms Stress induced chest pain Occurs during stressful situations, triggered by anxiety, sharp in nature

15. assessment 39yrs/M RVD- ve ; no known comorbidities, now presenting with 3-months history of unilateral headache associated with photophobia, neck stiffness and chest pain associated with palpitations. Normal neurological exam thus entertaining tension headache secondary to stressors ( social life and psychological issues).

16. investigations Brain CT to rule out any CVAs EKG to rule out cardiac causes of chest pain

17. Four stage assessment PROBLEM MANAGEMENT BIOLOGICAL Headache, chest pain Paracetamol Diclofenac Antacid PSYCHOLOGICAL R- headache I- thinking a lot, many internal thoughts C- no longer plays football E- get help to find permanent solution to his headache F- no complaint about her feelings F- fears that he might sometime fall on the pitch while playing football Counsel the patient, and refer to psychology for further counseling SOCIAL Drinks alcohol and smokes, plays football Applaud the patient to keep himself healthy through football, educate the patient on how to cut down alcohol and smoking since he is also willing to cut them down RELIGIOUS He’s a Christian but do not go to any church Applaud the patient to keep on believing and praying and to encourage him to visit nearby church