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The client arrived at the Outpatient Clinic accompanied by her mother. She raised complaints of severe headache that is mainly felt behind the eye, which started about ten weeks ago. The patient describes the pain as sharp and occasionally radiates to the entire head and the neck. The headache is felt weekly, sometimes lasting for over 15 hours, disrupting her task completion. She rates the headache as 8/10, where 10 indicates the most severe pain. She also reports that she is sensitive to light and loud noise. Staying in a dark room or sleeping are some of the alleviating factors that Mrs. Johnson’s identified. She has not tried any medications to treat the pain as she believes it is caused by her position when reading.
Plan
Primary Diagnosis and ICD-10 code
Migraines. Its ICD-10 code is G43.909. This is a type of unwarranted headache felt on one side of the head accompanied by sensitivity to light or sound with nausea and vomiting. This pain is debilitating and may interfere with the day to day functioning.
Differential Diagnoses
Tension headache: Its ICD-10 code is G44.209 (Schrepf et al., 2020). These are mild to moderate headaches that are not accompanied by sensitivity to light or sound and do not interfere with an individual’s workability.
Cluster headache: Its ICD-10 code is G44.0. This is an unusual type of headache in adults that presents with pain on one side of the head with additional symptoms of the autonomic nervous including tearing and reddening of eyes on the same side.
New daily persistent headache: Its ICD-10 code is G44.52. These are specific syndrome of headaches present for 15 days a month for the past three months. Schrepf et al. (2020), posits that the new daily persistent headache is self-limiting and has minor impairments in the quality of life.
Additional Laboratory and Diagnostic Tests: A CT Scan is a probable imaging test that uses a series of X-rays to produce a detailed cross-sectional image of the head to rule out any tumors.
Consults: seeking further consultations from a neurologist specialist is significant as they can make a diagnosis to rule out the probable neurological causes of the headache. According to Becker (2017), specialist conducts a comprehensive assessment of the reflexes, coordination, sensations, and vision for any disorders.
Therapeutic Modalities
Pharmacological: the classes of drugs used in treating migraine headaches include analgesics and anti-nausea medications. The combination of acetaminophen 250mg and caffeine 65mg 1 or 2 tablets per oral every 6 hours is effective for pain relief (Becker, 2017). An antiemetic medication such as metoclopramide 10mg intravenously every eight hours to control nausea and vomiting.
Non-pharmacological: Applying ice packs at the back of the head, taking hot showers, avoiding chocolates, and getting adequate sleep helps relieve the migraine headaches (Puledda & Shields, 2018).
Patient Education: The patient needs to be taught to avoid stress through meditation such as yoga and having an adequate resting time and sleep of 8 hours a day. Additionally, the patient should adopt a diary to monitor the headache for effective identification of the triggers.
Health Promotion: the client needs to be educated to engage in exercises to promote relaxation and stress relief. According to Puledda & Shields (2018), it is also imperative to screen for signs of bullying in the client, including visible scars or depressive mood. Furthermore, the healthcare personnel need to screen for sexually transmitted infections such as syphilis.
Disposition/follow-up instructions: the client needs to return to the clinic after six weeks to evaluate the effectiveness of therapy and assess any complications. Moreover, the client needs to be educated on the importance of adhering to the drug and non-pharmacological therapy.
References
Becker, W. J. (2017). The diagnosis and management of chronic migraine in primary care. Headache: The Journal of Head and Face Pain, 57(9), 1471-1481. Web.
Puledda, F., & Shields, K. (2018). Non-pharmacological approaches for migraine. Neurotherapeutics, 15(2), 336-345. Web.
Schrepf, A., Phan, V., Clemens, J. Q., Maixner, W., Hanauer, D., & Williams, D. A. (2020). ICD-10 codes for the study of chronic overlapping pain conditions in administrative databases. The Journal of Pain, 21(1-2), 59-70. Web.
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