Question

CASE STUDY TEMPLATE

Case study: Carol, a 50 yr old female patient presents to the office with a month-long history of intermittent headache. Headaches occur 1-2 times weekly, and last approximately 2-3 hours, and improve with over the counter treatment. Pain is described as sharp, and bilateral. Denies systemic symptoms. She has no history of headaches. The patient reports she recently lost her husband in an accident.

PMH includes Diabetes Mellitus Type 2

Social history: Current every-day smoker, ½ PPD, denies ETOH.

Family History: Mother deceased 89 years old with breast cancer

                             Father deceased 72 years old congestive heart failure

Medications: Hormone replacement therapy,

          bupropion XL (Wellbutrin) 150mg by mouth every day.

Vitals: Temp 100F, BP 150/90, HR 70, RR 18

working diagnosis to answer the following questions:

1: Are there any risk factors that predisposed this patient to the working diagnosis?

2: Consider Past Medical history, Social and/or Family history- does any of this influence or support your working diagnosis? if so, explain.

2: What is the classic subjective presentation for a client who has your working diagnosis? (HPI-OLD CART-PQRST)

4: List the body systems will you need to examine based on your working diagnosis, and include the findings that would be expected in that condition.

5: What procedures, labs or diagnostic studies will you need to order to support your working diagnosis, and indicate what results would support your diagnosis.

6: Using approved guidelines from your guideline texts (Fenstermacher or Cash & Glass), establish the treatment plan for this patient. Be specific and include medications you would order, strength, frequency, length of treatment and any referrals for interprofessional care.

7: What type of education will the patient require about the diagnosis and management plan?

8: What is your follow up plan for the patient?

Answer 1

Answers :

1 ) Risk factors that predisposed this patient to the working diagnosis

• · Current every-day smoker
• · Family History: Mother deceased 89 years old with breast cancer

- Father deceased 72 years old congestive heart failure(stressful events)

Recent loss of her husband personal loss or insecure feel may induce.

2 ) Considering the Past Medical history, Social and/or Family history- support working diagnosis includes

PMH includes Diabetes Mellitus Type 2

Social history: Current every-day smoker, ½ PPD, denies ETOH.

Family History: Mother deceased 89 years old with breast cancer

                             Father deceased 72 years old congestive heart failure

• · Headaches due to diabetes are often moderate to severe in nature. headaches can be a sign that your blood glucose is either too high or too low.
• · Smoking and second-hand smoke from cigarettes, cigars, and pipes can contribute to headaches for both the smoker and the non-smoker. Nicotine, one of the components of tobacco, triggers blood vessels to constrict, reducing blood flow to the brain and the covering of the brain (the meninges).
• · Family History: Mother deceased 89 years old with breast cancer

- Father deceased 72 years old congestive heart failure(stressful events)

- Recent loss of her husband personal loss or insecure feel may induce head ache due to stress ful life..

- Improve with over the counter treatment

3: What is the classic subjective presentation for a client who has your working diagnosis? (HPI-OLD CART-PQRST

PQRSTU	Questions Related to Pain	Patient symptoms
	·         What makes your pain worse?
Provocative
	·         What makes your pain feel better?
Palliative
	·         What does the pain feel like?
Quality	Note: If the client struggles to answer this question, you can provide suggestions such as “aching,” “stabbing,” “burning.”
	·         How bad is your pain?
Quantity	Sharp pain
	·         Where do you feel the pain?
Region	·         Point to where you feel the pain.	Bilateral headache.
	·         Does the pain move around?	No
Radiation	·         Do you feel the pain elsewhere?
	·         How would you rate your pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain you’ve ever experienced?
Severity	Note: The severity scale is an important assessment of pain and when used can provide evaluation of a treatment’s effectiveness. After eliciting a baseline, you may provide some sort of pain control intervention and then reassess the pain to see if it was effective.
(severity scale)
	·         When did the pain start?
Timing	·         What were you doing when the pain started?	· Headaches occur 1-2 times weekly. · 2-3 Hours.
	·         Where were you when the pain started?
	·         Is the pain constant or does it come and go?
	·         If the pain is intermittent, when did it last occur?
	·         How long does the pain last?
	·         Have you taken anything to help relieve the pain?
Treatment	·         Have you tried any treatments at home for the pain?	· Over-the-counter medications such as ibuprofen (Advil, Motrin IB, others), acetaminophen (Tylenol, others) and aspirin
	·         What do you think is causing the pain?
Understanding	Stress related to personal loss.

CPT guidelines components of the HPI:

• Location. What is the site of the problem? ...Head ache bilateral.
• Quality. What is the nature of the pain? ...sharp pain
• Severity. .. improve with over the counter treatment
• Duration. ...intermittent pain
• Timing. ... and last approximately 2-3 hours.
• OLD CARTS (Onset, Location/radiation, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity).

4 ) List the body systems will you need to examine based on your working diagnosis, and include the findings that would be expected in that condition

· Most headaches happen in the nerves, blood vessels, and muscles that cover a person's head and neck. Sometimes the muscles or blood vessels swell, tighten, or go through other changes that stimulate the surrounding nerves or put pressure on them.

5: What procedures, labs or diagnostic studies will you need to order to support your working diagnosis, and indicate what results would support your diagnosis.

• · A CT scan of the head might be recommended if you are getting daily or almost daily headaches to help rule out other causes of headaches. Magnetic resonance imaging (MRI): This test produces very clear pictures, or images, of the brain without the use of X-rays.

. 6 ) Using approved guidelines from your guideline texts (Fenstermacher or Cash & Glass), establish the treatment plan for this patient. Be specific and include medications you would order, strength, frequency, length of treatment and any referrals for interprofessional care.

• · Rest in a quiet, dark room.
• · Hot or cold compresses to your head or neck.
• · Massage and small amounts of caffeine.
• · Over-the-counter medications such as ibuprofen (Advil, Motrin IB, others), acetaminophen (Tylenol, others) and aspirin.

· Ibuprofen Dosage for pain :

Oral:
200 to 400 mg orally every 4 to 6 hours as needed
Maximum dose: 3200 mg/day (prescription strength); 1200 mg/day (over-the-counter)

Parenteral:
IV (Caldolor): 400 to 800 mg IV every 6 hours as needed
Maximum dose: 3200 mg/day

· Aspirin Dosage for pain :

• Adults: 325-650 mg orally/rectally once every 4-6 hours as needed
• Controlled/extended/delayed-release products (enteric-coated): 650-1300 mg orally once every 8 hours; not to exceed 3.9 g/day

· 7 )  What type of education will the patient require about the diagnosis and management plan?

i. Help patient identify triggers and develop a preventive strategies and lifestyle changes for headache prevention.

ii. Medication instruction and treatment regimen.

iii. Stress reduction techniques.

iv. Non pharmacologic therapies.

v. Follow-up care.

vi. Encouragement of healthy lifestyle and health promotion activities.

· 8 )  What is your follow up plan for the patient?

• Manage the symptoms of postdrome. ...
• Get plenty of rest. ...
• Limit exposure to bright lights. ...
• Nourish your body with sleep, food, and fluids. ...
• Ask for help and support. ...
• Explain the patient regarding the diagnostic studies needed for the detailed treatment ,if necessary.