Scenario
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Headache
History of present illness
Ms. Erin Davis is a 20-year-old woman who presents alone to the emergency department with a headache, Scale of the pain in the head is 6 out of 10, that relieve with acetaminophen and ibuprofen for headache. She has no associated fever, vomiting, neck pain, or other neurologic complaints. This headache is not atypical for her. Additional psychosocial history is notable for her estrangement from her mother, current unemployment, and financial dependence upon her boyfriend. She admits to incidents consistent with her being the victim of her boyfriend’s violence. The physical exam shows no evidence of head trauma; her neck is supple, the neurologic exam is normal. Two bruises of different ages are noted per examination – one on her left arm and a second on her left breast. Occupation: unemployed, living with her boyfriend in his studio apartment, she is not working since her boyfriend doesn’t make Substance use: smokes ½ PPD tobacco; no alcohol or illicit-drug use
Answer the following questions:
- 1)Discuss the questions that would be important to include when interviewing a patient with this issue.
- 2)Describe the clinical findings that may be present in a patient with this issue.
- 3)Are there any diagnostic studies that should be ordered on this patient? Why?
- 4)List, Discuss and describe the primary diagnosis and three different differential diagnosis and explain the reasoning for each diagnoses for this patient.
- 5)Discuss your management plan for this patient, including pharmacologic therapies, tests, patient education, referrals, and follow-ups.
Primary diagnosis:
Domestic Violence/ Intimate Partner
Differential diagnosis
Migraine Headache
Tension Headache
Cluster Headache.
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