No peripheral edema. Respiratory: Lung sounds clear over all fields, no advantageous sounds noted. Neurological: CN II-XII intact. DTRs 2+. Awake and alert. Oriented X 4. Speech clear and appropriate. No evidence of disordered thinking. Monofilament intact. Motor strength 5/5. Babinski reflex negative. Negative Brudzinski and Kernig sign. Pupils equal and reactive to light. Grip strength equal both hands, face symmetric. Short term and long-term memory intact. Headache rated 9/10 on pain scale intermittent. Denies photophobia or vomiting present with headache. Reports some nausea associated with headaches. Diagnostic results :
CBC with differential: Is used to detect any abnormalities, hypoxia secondary to anemia can cause headache (Dains, Baumann, & Scheibel, 2016). Blood Cultures: Blood cultures should be drawn in a patient who has a fever, headache, nuchal rigidity, and/or altered mental status (Dains et al, 2016). CT: Is used to detect intracranial disease and acute/chronic intracranial process. Patients with severe symptoms may indicate need for radiograph (Dains, Baumann, Scheibel, 2016). If the disorder does not respond to therapy may require a CT scan to determine the extent of the disease (Dains, Baumann, Scheibel, 2016). MRI: MRI is indicated in severe cases to see soft tissue pathology and brain tissue abnormality and is the first imaging choice for a brain abscess (Dains, Baumann, Scheibel, 2016). Lumbar Puncture (LP): An LP measures CSF pressure and analyzes the fluid for bacteria, glucose, protein, and lymphocytes (Dains et al., 2016). An LP is performed if CNS infection is suspected but is contraindicated if increased ICP is suspected (Dains et al., 2016). ESR (erythrocyte sedimentation rate): This is increased in presence of inflammation; perform if temporal arteritis is suspected (Dains et al., 2016). A . Differential Diagnoses Tension-Type Headache is the most common type of headache in adults and produces a bilateral, general, or localized often described as a frontotemporal band-like distribution. Patients described as a mild to moderate, non-throbbing pain, tightness, or pressure with a gradual onset (Dains et al., 2016). These types of headaches are associated with hunger, depression, or stress (Ball, Dains, Flynn, Solomon, & Stewart, 2015). MJ does state he has been under some stress lately from the debate team and is getting little sleep recently. A new study in the Journal of American Academy of Sleep Medicine (2009), shows there may be a link between headaches, naps and insomnia. Headaches due to insufficient or interrupted sleep are generally labelled "tension headaches" of psychogenic origin. In 25 healthy subjects, variable amounts of sleep loss (1-3 h for 1-3 nights) caused headaches lasting from 1 h to all day. The headache was most frequently a dull ache, a heaviness or a pressure sensation felt in the forehead and/or at the vertex. Migraine with aura is a neurological sign that indicates cortical and/or brainstem involvement. Bright lights, noise, or tension may precipitate these types of headaches (Dains et al., 2016).
- Summer '15
- Headaches, migraine, Medical diagnosis, Sinusitis