PBL Case Discussion: Neurologic Disorders Part One NR603 Week 1 PART 1

PBL Case Discussion: Neurologic Disorders Part One NR603 Week 1 PART 1 What further questions do you have for Christopher at this visit? O- When do the headaches occur? (Morning, evening, night, prior or during a period, ect.) While or after reading? (Migraine, eyestrain, tension headache) L- Where exactly do your headaches hurt? On one side of the head or both sides? (Migraine, tension headache, eyestrain) D- How long to your headaches last? Do you wake up with them? Gradual or sudden onset? (Migraine, tension headache) C- What do they feel like? (throbbing, dull, sharp, like a band is around your head, ect) (Migraine, tension headache, eyestrain) A- What are you doing when your headaches start? (Migraine) Are they provoked by stress or anxiety? (Tension headache) Do you get them after or during reading on the computer? (eye strain) R- What do you do to relieve the pain? (Sleep, dark room) (Migraine, tension headache) T- Do you take OTC medications for your headache? If so do they help? (Migraine, tension headache, eyestrain) S- How would you rate the pain of your headaches 0-10? (Migraine, tension headache, eyestrain) I would like discuss Christopher’s headache history without the mother present: Any family history of migraines? (Migraine) Any sensitivity to light or sound when you are having a headache? (Migraine) Do you see any flashes of light, or visual changed prior to your headache? (Migraine) Any blurred vision or vision changes? (Eyestrain) How many headaches do you get a day? How many a week? Month? (Migraine, tension headache, eyestrain) Do you feel depressed, anxiety, stressed? (Tension headache) How often are you on the computer, cellphone, or reading? (Eyestrain) What is your differential diagnosis list for this visit thus far with rationale? Tension headache (G44.209)- this is a common headache disorder common in children and adolescents. Childhood consists of rapid growth, emotional maturation, physiological perturbations, and hormonal changes which influence headache disorders. These headaches last from 30 minutes to 7 days, bilateral pressure, tightening or nonpulsating headache of mild to moderate intensity. These occur without nausea or vomiting but may have photophobia or phonophobia. This is brought on by stress, anxiety and depression (Buttaro, Trybulski, Bailey, Sandberg-Cook, 2013). Rational- Christopher is only 15; his headaches may be due to stress of school work, hormonal changes, anxiety or depression, more information is needed. Migraine (G43.909)- is a neurobiological disorder with attacks being based on external triggers. Prevalence of migraine increases with age, with puberty there is a higher prevalence for migraine in girls than boys. Migraines can be caused by sleeplessness, sunlight, hunger, exercise and watching TV (Buttaro, Trybulski, Bailey, Sandberg-Cook, 2013). Rational- Migraines are more prevalent in females, he only gets 5-6 hours of sleep a night, and he is on the computer a lot according to mom. Eye strain (H53.10)- a straining of the eye which is associated with near reading and writing where the eye accommodative and vergence process is more intense. Computer use, smart phones and e-books have increased the prevalence of eyestrain. Symptoms include headache, watery, burning or itching eyes, blurred vision, eye ache, dry eye sensation and double vision (Vilela, Castango, Meucci, Fassa, 2015). Rational- According to mom he is on the computer and his smart phone a lot. More information is needed. Post concussion syndrome (F07.81)- is a set of symptoms that may continue for weeks, months, or a year or more after a concussion – a mild form of traumatic brain injury (TBI. The rates of PCS vary, but most studies report that about 15% of individuals with a history of a single concussion develop persistent symptoms associated with the injury. A diagnosis may be made when symptoms resulting from concussion last for more than three months after the injury. Loss of consciousness is not required for a diagnosis of concussion or post-concussion syndrome. A common condition associated with PCS is headache. While most people have headaches of the same type they experienced before the injury, people diagnosed with PCS often report more frequent or longer-lasting headaches. Between 30% and 90% of people treated for PCS report having more frequent headaches and between 8% and 32% still report them a year after the injury. Rational- He is constantly getting headaches and since he had a concussion only 3 months ago, it is very possible he could have PCS. Based on your differential diagnoses list, identify what body systems you’d examine along with pertinent positive/negatives in each system and any diagnostic tests you would like to perform? Diagnostic tests: There is inadequate evidence that supports routine laboratory testing, but I would run a CBC, CMP, TSH, T4, to make sure that there is no active infection, anemia and that his thyroid is functioning within normal limits. EEG or neuroimaging for recurrent headaches in children without fever and a negative physical exam (Lewis et al., 2016). But since he has a history of concussion and the headaches have been going on for quite some time I would consider doing a CT of the head to rule out any head bleed or any other neurological abnormalities. Patients with acute onset of a worse headache, neurologic symptoms, and evidence of increased intracranial pressure require urgent consideration for a CT scan of the head (Goroll, Mulley, 2014). Vision test- a Snellen test assesses visual acuity (Butarro, Trybulski, Bailey, Sandberg-Cook, 2013). Physical Exam Positives/Negatives: Constitutional: Will include a through medial history (previous illnesses, trauma, headache history, ect), any fatigue, vital signs (HTN). Any weight loss, fever, fatigue, or weakness? Neuro: complete neurological exam including all 7 cranial nerves (looking for deficits or abnormalities), deep tendon reflexes (hyper or hypo reactive), gait (unsteady), HEENT: visual acuity (Snellen), (hesitancy, squinting, unequal vision), funduscopic exam (red reflex, retinal vessels, optic disc), sinus evaluation (looking for painful sinuses, nasal drainage, meningeal irritation and stiff neck, and temporomandibular joints (pain, click, pop) (Buttaro, Trybulski, Bailey, Sandberg-Cook, 2013). Musculoskeletal: evaluation of the muscles of the back and neck (muscle contractions in the face, neck and scalp, perhaps as a result of heightened emotions, tension or stress). (Mayo Clinic, 2016) References Part 2 Migraine without aura (G43.0)- defined as a recurrent headaches lasting 4-72 hours, unilateral in location, pulsating in quality, moderate to severe in intensity, aggravated by routine physical activity and associated with nausea and/or photophobia and phonophobia (IHS, 2013). Rational- Christopher meets migraine without aura by having 5 headaches with the following criteria including: headache lasting 4-72 hours, unilateral, pulsating, nausea, and photophobia (TV) (Fenstermacher & Hudson, 2016). Secondary DX: At this time I just don’t feel I have enough information to completely rule out PCS, so I am still including it as my secondary diagnosis. Since he is getting the headache so soon after his concussion this is still a very good possibility to a cause of his headaches. Post concussion syndrome (F07.81)- is a set of symptoms that may continue for weeks, months, or a year or more after a concussion – a mild form of traumatic brain injury (TBI. The rates of PCS vary, but most studies report that about 15% of individuals with a history of a single concussion develop persistent symptoms associated with the injury. A diagnosis may be made when symptoms resulting from concussion last for more than three months after the injury. Loss of consciousness is not required for a diagnosis of concussion or post-concussion syndrome. A common condition associated with PCS is headache. While most people have headaches of the same type they experienced before the injury, people diagnosed with PCS often report more frequent or longer-lasting headaches. Between 30% and 90% of people treated for PCS report having more frequent headaches and between 8% and 32% still report them a year after the injury. Rational- He is constantly getting headaches and since he had a concussion only 3 months ago, it is very possible he could have PCS. P. Diagnostic tests: There is inadequate evidence that supports routine laboratory testing, EEG or neuroimaging for recurrent headaches in children without fever and a negative physical exam (Lewis et al., 2016). But since he has a history of concussion and the headaches have been going on for quite some time I would consider doing a CT of the head to rule out any head bleed or any other neurological abnormalities. Patients with acute onset of a worse headache, neurologic symptoms, and evidence of increased intracranial pressure require urgent consideration for a CT scan of the head (Goroll, Mulley, 2014). Rx: Indomethacin 25mg tablet 1 tablet TID PRN for migraine Disp: 90, Refills: 2 (Buttaro, Trybulski, Bailey, & Sandberg-Cook, 2013) Education: A migraine is defined as a recurrent headaches lasting 4-72 hours, unilateral in location, pulsating in quality, moderate to severe in intensity, aggravated by routine physical activity and associated with nausea and/or photophobia and phonophobia (IHS, 2013). You meet the criteria by having 5 headaches with the following: headache lasing 4-72 hours, unilateral, pulsating, nausea, and photophobia (TV) (Fenstermacher & Hudson, 2016). Take your indomethacin as soon as you feel a headache coming on, this is an abortive medication and should stop your headache from becoming a migraine. Take your indomethacin with food to avoid GI upset. A migraine diary would be helpful to monitor possible triggers and treatment effectiveness. If you have a headache that is thunder clap in nature or the worst headache of your life, go to the emergency room for further work-up (Fenstermacher & Hudson, 2016). Conservative measures: Make sure you are getting at least 8 hours of sleep a night as this can trigger migraine headaches. Limit caffeine intake, eat three meals a day and make sure you are getting enough sleep. Other things that can trigger a migraine include: dairy products, processed meats (hot dogs, bologna), beans, peas, onions, pickles, olives, white bread/sourdough, soups containing MSG, citrus fruits, bananas, figs, raisins, papaya, kiwi, plums, pineapples, avacados, chocolate, ice cream, peanut butter and stress (Buttaro, Trybulski, Bailey, & Sandberg-Cook, 2013). Limit you screen time, TV, phone, gaming, computer, just a few examples. Referrals: Possible referral to headache specialist if treatments are not working and headaches persist (Fenstermacher & Hudson, 2016). Follow up: 2 weeks to review headache diary and to evaluate efficacy of medication regimen (Fenstermacher & Hudson, 2016). References Buttaro, T. M., Trybulski, J., Bailey, P., & Sandburg-Cook, J. (2013). Primary Care: A collaborative practice (4th ed.). St. Louis, MO: Elsevier Mosby. Fenstermacher, K. & Hundson, B. T. (2016). Practice Guidelines for Family Nurse Practitioners (4th ed.). St. Louis, MO: Elsevier. Goroll, A. H.,& Mulley, A. G. (2014). Primary care medicine: Office evaluation and management of the adult patient (7th ed.). China: Wolters Kluwer. Lewis, D. W., Ashwal, S., Dahl, G., Dorbad, D., Hirtz, D., Prensky, A., & Jarjour, I. (2016). Practice prarmeter: evaluation of children and adolescents with recurrent headaches. American Academy of Neurology, 59(4), 490-498. The International Headache Society (IHS). (2013). Retrieved from Migraine: http://ihs-