Headache and pain CASE STUDY
Assume you are the nurse practitioner caring for this patient, the following questions separately, one for headache and the other for pain. Provide rationales and possible diagnoses and give supportive evidence using APA format.
Room 1: HPI: 16yo Raena Regis reports history of a unilateral headache for 4 days that last no longer than three hours but occur one after another. Described pain as throbbing and worsens with any activity and on days when she drinks a lot of coffee. Mother has a past medical history of migraine.PE: T-98.2; BP 118/66, P-99, R-18, Pain-6/10HEAD: intermittent severe headaches that occur in clusters and are located near the forehead. cranial/cervical muscle tenderness, photosensitivity and nausea reported during headaches
Musculoskeletal: Decreased neck Range of motion, sensation intact to all extremities
How would you further assess this patient and what treatment options would be considered?
Room 3: Renata reports generalized achiness that is mostly localized to her joints (hands, fingers, knees).PE: T-98.0, BP 112/75, HR 110, R-20BLE/BUE: HAND/FINGERS/KNEE: resident verbalizes pain on flexion and extension of both upper and lower extremities, patient noted limping on movement around the exam room accompanied by facial grimacing. Pain scale 6/10.Swelling noted in joints of hands, fingers, and knees, no deformities or redness noted. The patient reports pain worsens throughout the day and joints become stiff.
How would you further assess this patient and what treatment options would be considered?
