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Name: K.J |
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Pt. Encounter Number: |
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Date: 16/03/2017 |
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Age: 33 years old |
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Sex: Male |
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SUBJECTIVE |
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CC: “I have an excruciating pain in my right eye. It radiates to other areas of my head, face, neck and even shoulders.” |
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HPI: A 33-year-old patient presents to the office with the complaint of headache lasting for 4 weeks. He describes the headache as initially dull, but it increases, reaching from 3 to 9 point on a 1 to 10 pain rating scale. The pain has not disappeared but intensified. It is often one-sided and characterized by excessive tearing. The headache is often accompanied by the redness of the right eye and a stuffy runny nose on the side that is affected. Besides, the patient says that sweating on the face and forehead often accompanies the headache. According to the patient, the headache occurs seasonally during spring and lasts for up to six weeks. It is then followed by a pain-free remission period that lasts 8 months before another attack develops. The patient also says that the headaches occur daily usually at night after going to bed, sometimes even several times during the day, with each attack lasting for 1 hour. The patient claims that the pain often stops suddenly just as it begins. The patient visited the office today to seek care because the headache has intensified and a fever and nausea have developed. |
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Medications: Ibuprofen for pain relief. |
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PMH Allergies: None. Medication Intolerance: Denies medication intolerance. Chronic Illnesses/Major Traumas: Denies illnesses or traumas. Hospitalizations/Surgeries: Denies hospitalizations or surgeries. |
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Family History The patient lives with his wife and two children, a daughter and a son, who are 5 and 3 years old respectively. The wife is healthy and denies any recent illnesses. The patient’s parents are both dead. The father, who was an alcoholic, died of a heart attack, while the mother died in a road accident. |
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Social History The patient is a college graduate who works in a steel factory as a shift supervisor. He lives in a rented apartment with his wife and two children. The patient says that he smokes cigarettes and drinks alcohol moderately. |
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ROS |
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General Negative for weight change; positive for fever and night sweats. |
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Skin Denies rashes, bruising, discolorations, bleeding, delayed healing, changes in moles, or lesions. |
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Cardiovascular Denies chest pain, edema, orthopnea, or PND. |
Respiratory Denies cough, hemoptysis, wheezing, pneumonia, dyspnea, or tuberculosis. |
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Eyes Positive for eye redness; denies blurring, use of corrective lenses, or changes in acuity. |
Gastrointestinal Denies abdominal pain, constipation, hemorrhoids, hepatitis, ulcers, eating disorders, or black, tarry stools. |
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Ears Denies pain, discharge, hearing loss, or ringing in ears.
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Genitourinary/Gynecological Denies urgency, color change of urine, frequency burning, prostrate, urinary complaints, or PSA. |
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Nose/Mouth/Throat Positive for a runny nose; denies sinus problem, dental disease, hoarseness, or throat pain. |
Musculoskeletal Denies back pain, stiffness, fracture, joint swelling, or osteoporosis. |
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Breast Denies bumps, lumps, or changes. |
Neurological Denies seizures, syncope, weakness, transient paralysis, or black-out spells, |
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Heme/Lymph/Endo Denies swollen glands, blood transfusion, increased hunger; positive for night sweats. |
Psychiatric Denies depression, anxiety, suicidal ideation, or sleeping difficulties. |
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OBJECTIVE |
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Weight: 67kg BMI: 21 Temp: 37.70c BP: 120/80 |
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Height: 6’0” Pulse: 71 bpm Resp: 22 |
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General Appearance The patient is well-appearing, alert and oriented in place and time. He does not show signs of acute distress. He also answers the questions appropriately. |
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Skin His skin is warm, dry, clean and intact. There are no noticeable rashes or lesions. |
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HEENT The head is normocephalic and atraumatic; redness noted; no lesions. No conjunctival injection. Ear canals are patent; tympanic membranes are pearly gray with landmarks. Nasal mucosa is pink, while turbinates are normal. Neck is supple, full ROM and without cervical lymphadenopathy. Pharynx is nonerythematous, and the teeth are intact. |
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Cardiovascular S1 and S2 with regular rate and rhythm. No murmurs, extra sounds, clicks or rubs noted. No edema noted. |
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Respiratory Chest wall is symmetric, while respirations are easy and regular. Lungs are clear to bilateral auscultation. |
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Gastrointestinal No abdominal obesity. Abdomen is soft and non-tender; no hepatosplenomegaly noted. |
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Breast The breast is free from tenderness, masses, discharge, wrinkling, dimpling, or skin discoloration. |
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Genitourinary Bladder nondistended, no CVA tenderness. Coarse pubic hair is distributed normally; skin color with consistent pigmentation. Both testes are palpable, without masses, lesions, hernia, or uretheral discharge. Prostrate is smooth, non-tender, without nodules, normal size. Sphincter tone looks firm. |
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Musculoskeletal Full ROM in all four extremities. |
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Neurological K.J. speaks clearly, with normal tone. Th posture is erect. His balance is stable and gait normal.. |
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Psychiatric The patient is alert and oriented in place and time. He is dressed appropriately. He maintains eye contact. Speaks clearly at a normal rate and cadence and answers the questions appropriately. |
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Lab Tests Lab tests are still pending. |
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Special Tests Blood and urine tests. |
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ANALYSIS |
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· Differential diagnoses: 1. Allergen exposure 2. Cyclical migraine 3. Eye disorder 4. Pituitary tumors 5. Hypnic headache 6. Trigeminal neuralgia · Final diagnosis: Cluster headache Subjective and objective patient data indicate that he is suffering cluster headache. Thus, complaints of one-sided headache lasting for a month, accompanied by redness of the eye on the affected side and excessive tearing, that occurs seasonally with a period of remission, develops several times during a day and continues for one hour are all important symptoms that are associated with cluster headache (Robbins, Starling, Pringsheim, Becker, & Schwedt., 2016). Objective data, including sweating, high body temperature (37.70C) and eye redness confirm the diagnosis. |
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PLAN |
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· Further testing: Lumbar puncture test to rule out meningitis or infection around the spinal cord. · Medication: Ergotamine, particularly dihydroergotamine-45 (DHE-45) administered intravenously has been reported to provide pain relief within 15 minutes (Gooriah, Buture, & Ahmed, 2015). · Education: Educate the patient on the importance of alcohol and smoking cessation. Inform the patient about the importance of sticking to a regular sleep pattern because cluster headache can be triggered by disruption of normal sleep schedules. Educate the patient on the need to join a headache support group, to connect with other people with similar experiences as well as to get more information (Holle et al., 2013). · Non-medication treatments: Yoga, acupuncture, meditation, tai chi, and homeopathy are important non-medication treatments to consider (Holle et al., 2013). · Follow-up: Follow-up should be conducted after one week of treatment to determine the effect of the prescribed medication and to collect the results of the blood tests. |
The quality and relevance of subjective and objective helped to establish the diagnosis of cluster headaches. Moreover, subjective and objective data agreed with those presented in the evidence-based articles referred. Therefore, the chosen management approaches meet prescribed standards and are accurate.