Note 1
CC: “Really bad headache that won’t go away” since yesterday afternoon.
HPI:
36y/o female smoker (15 pack-years) and chronic cough x 4 years presents with c/o right sided headache that began yesterday afternoon while at work and was severe enough that she had to leave work. The patient is known to your clinic and had her last complete history and physical about 3 months ago.
Onset: about 3 o’clock yesterday
Location: the right side of my head and the right forehead
Duration: since then (about 18 hours now)
Character: throbbing/pounding
Aggravating/Alleviating: going outside makes it worse. Lying down with a cold cloth over my eyes makes it a little better
Radiation: none
Related symptoms: About 30minutes before it began, I started seeing weird wavy lines. “Do you think I’m having a stroke?”
Timing: constant since yesterday. Began after working at computer screen for about 4 hours on a report due yesterday at 5:00, “but I had to leave before it was done”. She has had this kind of headache before – 3 times in the past 2 years, “But this was the worst”.
Severity: 8-9/10
Physical Exam:
VS: P100, R 20, BP 140/88, Temp 98.6 ͦF
Pupils are round and reactive to light, but patient notes pain when the light (photophobia) is directed at her eyes.
She appears in considerable distress and seems to want to avoid opening her eyes or moving her head
Extra ocular movements are full, but patient notes pain on extreme lateral gaze visual acuity is unchanged from last exam (20/40 Bilaterally)
Examination of her chest reveals clear lungs and a regular heart rate and rhythm with no murmurs or gallops
Inspection of her nose shows pink mucosa, no masses or lesions, bilateral nares are clear of discharge and patient can breathe through both sides normally (R/o sinusitis, infection,)
Penlight exam of her throat shows no redness or exudates, palate lifts symmetrically, tongue protrudes in the midline
He color is generally within normal limits with no cyanosis and her conjunctivae are pink.
Skin is warm, moist, and has normal turgor
What is your assessment (include a differential diagnosis)?
The sensitivity to light suggests a headache due to a migraine, especially since putting a cloth over her eyes making it darker makes it better. The wavy lines are suggestive of the ‘aura’ people describe as seeing during migraines. I was thinking eye strain could be an additional contributor to her headache as she describes her work being in front of a computer.
What is your plan for this patient?
Give medication for migraine and counsel PT to take it when she feels the headaches begin. Advise PT to write down triggers/diary of headache. Come back to clinic or ED immediately if symptoms increase in severity or develop nausea/vomiting. Suggest taking more breaks between looking at the computer to see if it helps with decreasing the headache frequency.
Refer to optometry to assess eye strain.
Note 2
The previous patient has been diagnosed with probable migraine headache and treated with amytriptilene 50 mg. at bedtime and zolmitriptan 2.5 mg via nasal spray – up to two doses for an acute headache. She comes back to see you a few months later and reports that she has had no headaches since the last visit. However, she has been feeling “really sleepy all day” and feels like she isn’t functioning so well at work. She also says that about a month ago she started to see the “wavy lines” and feel a little nauseous so she took one dose of the zolmitriptan and her complaints resolved without ever having a headache. Your exam is essentially the same as the last time except that she is not having pain on EOMs or when the penlight is shone into her eyes.
She has a problem list in her chart and #3 is Migraine Headache – Uncomplicated with visual aura
What is your assessment?
The medication she was prescribed for daily use, Amytriptilene, may have sedative side effect. Although less likely, as 36y/o menstruating female, she may be borderline anemic or iron deficient.
What is your plan?
Check side effects of Amitriptyline. Order CBC, anemia/iron panel to rule out potentially masked anemia.
SOAP note for this visit:
S: 36y/o diagnosed with migraines last month and prescribed Amytriptilene daily as treatment comes back a few months later complaining of sleepiness. Otherwise, medication helps resolve headache and “wavy lines”.
O: VS: P100, R 20, BP 120/88, Temp 98.6 ͦF, 20/40 visual exam. Eyes are not sensitive to penlight. No pain on EOMS. Lungs clear. No other significant findings.
A: DDX: Most likely: Sedation secondary to medication, Less likely: Anemia
P: Change to new medication with less sedative side effects and see if sleepiness resolves. Schedule follow up visit in one month.
