Beth Brown IHuman

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Template Below is the template you are to follow when developing your management plan. It is to be completed as a Word document and then you can copy and paste it in to iHuman. Also, always be sure... to complete the EMR on the case. Use this template with each case. It is not a SOAP format as that is not required. 30 points will be deducted for not utilizing the template. Primary Diagnosis and ICD-10 code: Also include any procedural codes. Migraine headache (G43.909)- Migraine headaches are a type of headache that varies in intensity and causes throbbing pain usually on one side of your head (New ways to manage migraines, 2018). Individuals may experience an aura before the onset of a migraine, an aura is a neurological event, typically a visual disturbance such as a pulsing or flashing light, blurriness, or even partial loss of vision (New ways to manage migraines, 2018). Other symptoms individuals may report is sensitivity to light, nausea, occasional vomiting, and phonophobia (New ways to manage migraines, 2018). They usually would rather retreat to a dark quiet room and sleep off the migraine (New ways to manage migraines, 2018). A migraine can last anywhere from hours to a few days depending on the severity of the headache (New ways to manage migraines, 2018). A migraine can be very debilitating to the point where the person miss days from work, and miss out on pleasurable activities and time with family (New ways to manage migraines, 2018). In order to receive a diagnosis of migraine headache, the headache must last between 4 and 72 hours, it’s typically on one side of the head, with the characteristics of a throbbing/pounding sensation, and moderate to severe pain that gets worse with physical activity (New ways to manage migraines, 2018). The individual has to experience at least 5 attacks that meet most or all of these criteria in order to be diagnosed with migraine (New ways to manage migraines, 2018). This diagnosis was This study source was downloaded by 100000852290574 from CourseHero.com on 01-10-2023 13:36:58 GMT -06:00 https://www.coursehero.com/file/92429345/Beth-Brown-IHumandocx/ chosen as the primary diagnosis because this patient has been having several of these symptoms as described above over several months and they have been becoming more frequent and intensifying. She also has a positive family history of headaches, and she mentioned how her headaches are triggered by a lack of sleep, stress, and certain foods. Hence the reasoning behind ordering an MRI of the brain as a diagnostic test and to also rule out any trauma noted to the brain that has not been documented or missed. Differential Diagnoses- Why? What? How? 1. Tension headache (G44.209)- A tension type headache is one of the most common primary headache disorders (Kong et al., 2018). Individuals with this type of headache complains of a tight band like feeling around their head (Kong et al., 2018). The etiology of TTH is thought to be of a muscular origin and peri-cranial muscle tenderness, which is a unique feature of TTH (Kong et al., 2018). Individuals may report having a decrease in work efficiency and a reduction in their social life (Kong et al., 2018). To receive a diagnosis of tension type headache the patient must present with symptoms such as mild nausea, photophobia, or phonophobia, and report that their headaches were not aggravated by routine physical activity (Kong et al., 2018). This diagnosis was chosen because of the patient report of feeling a band like pain that spread across her forehead when she experiences this type of headache. She also reported that she felt the tension in her neck and shoulder region which helps to shed light on the thought that a TTH is muscular in region. This study source was downloaded by 100000852290574 from CourseHero.com on 01-10-2023 13:36:58 GMT -06:00 https://www.coursehero.com/file/92429345/Beth-Brown-IHumandocx/ 2. Cluster headache (G44.009)- A cluster headache is a neurological disorder that presents with unilateral severe headache symptoms accompanied by nasal discharge and red or watery eyes (Wei, Khalil & Goadsby, 2019). Individuals may describe a cluster headache attack as an intense and severe headache occurring on one side of the head, typically in the supraorbital, retro-orbital, temporal regions and arising from deep within (Wei, Khalil & Goadsby, 2019). Most individuals will describe it as their worse headache ever experienced as the pain ramps up quite quickly once it starts and typically remains for 15- 180 minutes when left untreated (Wei, Khalil & Goadsby, 2019). Individuals experiencing a cluster headache are typically agitated, restless, and prefer to rock in a sitting position massaging the area of pain (Wei, Khalil & Goadsby, 2019). An individual can experience up to 8 cluster headaches a day with the majority of them occurring at night (Wei, Khalil & Goadsby, 2019). This diagnosis was chosen as a differential diagnosis because of the report the patient gave that her headaches are normally on one side of her head. However, this diagnosis was ruled out because she denied ever having cranial autonomic symptoms such as rhinorrhea, watery eyes, periorbital swelling, or specified if the majority of the headaches occurred at night. Which are some of the symptoms individuals who experience cluster headaches have. [Show More]

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