Instructions
Response posts to peers have no minimum word requirement but must demonstrate topic knowledge and scholarly engagement with peers. Substantive content is imperative for all posts. Please proofread your response carefully for grammar and spelling. Substantive means that you add something new to the discussion supported with citation(s) and reference(s), you are not just agreeing. This is also a time to ask questions or offer information surrounding the topic addressed by your peers. Personal experience is appropriate for a substantive discussion, however should be correlated to the literature. All posts should be supported by a minimum of one resource, ideally within the last 5 years. Journals and websites must be cited appropriately. Citations and references must adhere to APA format.
Please respond to two peers’ posts regarding their plan.
- What did you find interesting about their response?
- How did their plan compare to yours?
- Do you agree with their plan and recommendations?
PEER 1: PAOLA T.
The first part of the discussion board is to identify all pertinent positive and negative information
Pertinent positives: head pain that started 3 days ago, school called in the last 3 days since pt. has been going to the nurse reporting headache. School nurse gave Tylenol, but it did not help. Aunt recently got custody of patient since patient’s died in a MVA, pt. having a tough time adjusting to new living conditions. PMH asthma, measles, and mumps; allergies to Ibuprofen. Headache like squeezing pain. Pertinent negatives: Denies recent falls or injuries to head, denies visual changes, ear pain, sore throat, nasal congestion, fever, or chills. Denies neck pain, reports not getting headaches before. Has not been a change in his diet, continues to eat and drink well, attends the same school. No firearms, tobacco, alcohol, illicit drugs in home. Remarkable ROS except reports headaches like squeezing pain and feeling sad at times. Remarkable physical exam.
What other questions may you want to ask the patient?
When did the headaches started? Where in your head does it hurt when you have the headache? Is it the headache on one side of the head? How long does the headache last at a time? How would you describe your headache, throbbing, achy? What makes your headache better? What makes you headache worse? Does your headache pain radiate somewhere else? Is there a time of the day that the headache is worse? When do you get the headache how bad is it (using a face scale)? How are you doing with living with your aunt and cousins? How do you feel about your parents? Do you feel alone? Are you stressed and sad? When you get the headache do you see an aura? Have you been sleeping well? Does light bother you when you have a headache? Do loud noises bother you when you have a headache? Have you noticed something that triggers the headaches? Is your headache worse with physical activity? Do you get nauseous when you have your headache? Have you vomited? Do you eat chocolate, cheese, and citrus fruit? Is there any family history of migraines?
How will you address these findings?
Patient just lost his parents to an MVA, is living now with aunt and cousins; this are abrupt changes for any child and causing much sadness and stress in our 7-year-old patient which could be the cause of his migraines. The way I would address these findings is by referring the patient to a therapist to help deal with the loss of his parents and his new living arrangements.
Now create a plan utilizing clinical practice guidelines for the priority diagnosis.
Diagnosis: Migraines- ICD 10 – G43.909 as evidenced by head pain for 3 days described as a squeezing pain. Prevalence rates for migraine headaches for a kid aged seven like our patient is 37% to 51% and before 10 years of age migraine headaches are more common in males like our patients than in females (Garzon Maaks et al., 2020).
Diagnostics: N/A. No initial test needed at the beginning since pt. has no indicator for urgent CNS imaging like a brain CT/ MRI which would be an option in the future if he does not respond to treatment.
Therapeutic: Unfortunately, our patient is allergic to Ibuprofen so that would not be an option, also Tylenol was not helping his migraines so that is out of the picture as well. Therefore, treatment should be a triptan (5-hydroxytryptamine 1 agonist) for his acute episodes or migraines. Patient to take nasal Imitrex which is approved for kids 5 years of age and older; one actuation (5 mg) in each nostril x 1, may repeat after 2 hours (Epocrates, 2022). Patient is going through so much stress and headaches are affecting his quality of life it is pertinent to also prescribe a prophylactic migraine medicine. First line medicine is propranolol (a beta blocker) but pt. has a history of asthma so that is not an option, second line is Topiramate but that is only approved for 12 years old or up and third line therapy is Amitriptyline which would be a great option for this patient because it can help with his sadness and prevent migraine attacks at the same time (Epocrates, 2022). Amitriptyline for migraine headache prophylaxis is approved for 2 years old children and up and the dose for our patient would be 0.25-1mg/kg/dose at night, starting with 0.1-0.25 mg/kg/dose PO and may be increased every 2 weeks (Epocrates, 2022). Therapy for Amitriptyline needs a pediatric neurologist supervision.
Educational: Triptan should be used as early as possible after an attack. Do not stop taking Amitriptyline without tampering dose and consulting healthcare provider. Side effects that may disappear as pt.’s body gets used to nasal Imitrex are burning/soreness in nose, dizziness, change in taste, drowsiness, feeling strange, lightheadedness, flushing, muscle aches, nausea and redness in upper torso and face (Mayo Clinic, 2022b). Adverse effects with the triptan that needs to be reported right away to healthcare provider are mild chest pain, pounding heartbeat, difficulty swallowing and rash or hives (Mayo Clinic, 2022b). Symptoms of overdose of Amitriptyline are drowsiness, low body temperature, muscle aches, sleepiness, weakness, and clumsiness; if patient has these symptoms pt. needs emergency help (Mayo Clinic, 2022a). Secondary prevention is important to mention to patient like relaxation therapy, biofeedback, and pt. to avoid triggers like cheese, chocolate, and stress reducing strategies need to be put in place (Epocrates, 2022). Pt to keep a diary for his headaches, when do they occur, what triggers them as much pertinent information as possible and to bring it to follow-up appointment in 1 week.
Consultation/ Collaboration: Refer to therapist/ psychologist. Refer to neurologist to help manage migraines and medications (amitriptyline).
References
Epocrates. (2022). Migraine headache in children. https://online.epocrates.com/diseases/67842/Migraine-headache-in-children/Treatment-Options
Garzon Maaks, D. L., Starr, N. B., Brady, M. A., Gaylord, N. M., Driessnack, M., & Duderstadt, K. G. (2020). Pediatric primary care (7th ed.). Elsevier.
Mayo Clinic. (2022a). Amitriptyline (oral route). https://www.mayoclinic.org/drugs-supplements/amitriptyline-oral-route/before-using/drg-20072061
Mayo Clinic. (2022b). Sumatriptan (nasal route). https://www.mayoclinic.org/drugs-supplements/sumatriptan-nasal-route/side-effects/drg-20066193?p=1
PEER 2: JD
The first part of the discussion board is to identify all pertinent positive and negative information.
Pertinent positive information: Headaches for the past three days, aunt got custody of him about two weeks ago, Mother and father recently decreased from a car accident, reports feeling sad at times, and flat affect. Squeezing head pain.
Pertinent negative information: Denies recent falls or injuries to the head, denies fever and neck pain, no visual changes, denies dizziness, orientated x 3, normocephalic, no lumps or bumps noted on his head, good muscle strength and tone.
What other questions may you want to ask the patient?
I would begin by asking the child if he has had headaches in the past like this; If he has nausea associated with the headaches; noticing any auras or changes in his vision when he has the headaches; if he feels sad more than usual since his parents passing; if he is more nervous going to school now or nervous living with his aunt; does anything make the headache worse or better?
How will you address these findings?
I would begin by conducting a neurological exam on the patient to ensure no deficits are noted that could be causing his headaches. I would also address these findings by determining the child’s diet and water intake, which can cause headaches in young children. I would address these findings by interviewing the child’s aunt and then with the child alone. I would begin by using a PHQ-9 questionnaire and talking through it with the patient. I would also use Beck’s depression inventory to assess the child and determine if the cause for his headaches is somatic from depression and stress (Alsaad et al., 2022). Also, if the child had issues in school with concentrating or studying, I would make sure these are addressed with his teachers.
Now create a plan utilizing clinical practice guidelines for the priority diagnosis.
The priority diagnosis for this child would be tension headaches related to his recent parent’s accident, moving in with his aunt, and increased stress. Due to the child explaining his headaches as “squeezing” and occurring due to the added stressors in his life, the child is likely suffering from tension headaches. It would also be beneficial to obtain labs from this child to include CBC, CMP, B12 levels, thyroid panel, and liver enzymes (Alsaad et al., 2022). These labs can help to rule out some differentials that can mimic the child’s symptoms. Many children feel tension-type headaches due to increased stress at school or home, which can transmit into somatic symptoms such as headaches, stomach aches, or body pains (Johns Hopkins Medicine, 2022). It would be appropriate to treat this child with Tylenol 500mg PO PRN every 4-6 hours; I would educate the child’s aunt to keep a log of his headaches in a journal and write down the things he was doing that precipitated the head pain. I would also educate the child’s aunt to allow the child a quiet, dimly lit area to rest and take a nap after school. Using ice packs and even taking a warm shower or bath after school can help decrease symptoms related to stress. It would be crucial for this child to be referred to a therapist for cognitive behavioral and biofeedback stress relaxation interventions. This child would benefit from meeting with a school counselor due to the recent significant deaths in his life (Sheikh, 2021).
References
Alsaad, A., Azhar, Y., & Nasser, Y. (2022). Depression in children. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK534797/
Johns Hopkins Medicine. (2022). Headaches in children. https://www.hopkinsmedicine.org/health/conditions-and-diseases/headache/headaches-in-children
Sheikh, H. ( 2021). Symptoms and treatment of tension headaches in children. VeryWell Health. https://www.verywellhealth.com/symptoms-and-treatment-for-tension-headache-in-children-1719564
For the writer: this is what I posted. You do not need to respond to this. I am including it as background information if it helps. I am also adding the case study the class is discussing.
· Pertinent positive
-head pain that started three days ago
-Tylenol doesn’t seem to help
-Allergies:Ibuprofen
-Asthma
-Had measles/mumps at the age of 4.
-Recently moved in with aunt, uncle & cousins (3 of them: 17, 15, 14). Mother/father deceased. –Been having a hard time adjusting to living with new family
· Pertinent negative
-denies recent falls or injuries to the head
-Denies visual changes, ear pain, sore throat, nasal congestion, fever, or chills.
-denies neck pain
-not getting headaches before
-no current changes in visual acuity,
-Ears. Denies hx of ear pain, discharges, tinnitus and hearing loss.
-Nose. Denies hx of nasal obstruction, discharges, and bleeds.
-Throat. Denies hx of sore throat, hoarseness, dysphagia, and throat pain. Neck. Denies any neck pain.
-Cardiovascular. Denies pain to the chest area, palpitations, bruits, and murmurs.
-Gastrointestinal. Denies abdominal pain, burning, acid reflux, nausea, vomiting, bloating, constipation, diarrhea, pain and straining on defecation, no blood in the stool, or changes in bowel habits. Denies poor appetite.
-Neurologic. Denies any history of seizures.
-Head: no tenderness during palpation, no lumps, lesions, or masses
-Tympanic membranes gray and intact, with a cone of light noted. Pinna and tragus are non-tender.
-Neck full ROM. Supple, no lymphadenopathy.
· What other questions may you want to ask the patient?
Where does it hurt ( is it only on one side or both)? Does it come and go, or is it always there? I would try and ask to describe the pain. I want to know if anything makes the pain better or worse, and I would use the face scale to ask for the intensity of the pain. I want to know if the pain goes anywhere else. I want to know the exact dose and frequency of Tylenol that is being given. I want to know if he has been sick in the past month, has dizziness, or has lost his balance. Is there something, a sensation that lets him know the headache is about to start? Has there been a significant weight loss? Has there been blurry vision, photophobia, or phonophobia? How is he doing in school? Has he had trouble concentrating? Is there a history of migraines in the family?
I also want to ask about his home activities and playtime. I want to know how he is coping with his parents’ loss.
· How will you address these findings?
Headaches in children and adolescents have high incidence and prevalence rates (Iannone et al., 2022). The prevalence of headaches varies from 5.9 to 88%, depending on diagnostic criteria and age. The frequency is higher in males before puberty, with an inverse relationship after that (Iannone et al., 2022). Pediatric migraine is potentially a disabling disorder with substantial clinical differences compared to the adult form. Primary headaches in pediatric patients follow the International Headache Society (IHS) criteria of shorter duration, less than 4 hours, and unilateral/bilateral localization of pain (Iannone et al., 2022). I will address the findings as a possible primary headache.
· Now create a plan utilizing clinical practice guidelines for the priority diagnosis.
Plan
Diagnostics: N/A. The evaluation of pediatric headaches is a systematic approach where you first take a thorough medical history, physical exam, and neurologic examination. No evidence supports routine laboratory studies, lumbar puncture, or electroencephalogram (Koch & Oakley, 2018). No evidence supports routine neuroimaging in children with recurring headaches who have a normal neurologic exam either (Koch & Oakley, 2018). Neuroimaging in children with headaches should be considered when medical history, physical exam, and neurologic examination findings warrant further investigation (Koch & Oakley, 2018).
Therapeutics:
Many patients with moderate-to-severe migraine respond well to oral treatment with analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) administered at the time of an attack (Koch & Oakley, 2018). However, we know this patient is allergic to Ibuprofen, so we must be cautious with NSAIDs. Assuming that he is receiving the correct dose of Tylenol for his weight, we know it is not helping. We must reserve serotonin 5-HT receptor agonists for moderate-to-severe headaches unresponsive to over-the-counter analgesic therapy (Koch & Oakley, 2018). Unlike ergot derivatives, triptans offer selective activity, well-established dosing regimens, safety, and tolerability. Sumatriptan, almotriptan, zolmitriptan, and rizatriptan have earned US Food and Drug Administration (FDA) approval for acute pediatric migraine (Koch & Oakley, 2018). I would prescribe rizatriptan orally disintegrating tablet 5 or 10 mg (Hotop & Ferguson,2020).
Educational:
Patients must be educated and able to use their medication as early during the headache as possible. This requires ready access to medications in school, home, and social situations (Koch & Oakley, 2018). Pediatric patients must avoid medication overuse. Analgesics and NSAIDs must be limited to 2 to 3 days or less weekly. A headache diary helps track drug use patterns (Koch & Oakley, 2018).
Triptans should be used less than six times a month and must not be used within 24 hours of each other or with other ergots (Koch & Oakley, 2018). Adverse effects are paresthesia, sleepiness, dizziness, warm/hot sensation, nausea, weakness, myalgia, fatigue, and tightness in the chest or throat (Koch & Oakley, 2018). Adverse effects of triptan generally last less than 30 minutes.
Prophylaxis is only considered in patients who experience at least 3 to 4 migraines monthly and those for whom acute treatments prove insufficient and poorly tolerated(Koch & Oakley, 2018). Children who experience significant pain and disability also may warrant prophylaxis. The only agent the FDA has approved for preventive use in children is topiramate (Koch & Oakley, 2018).
Collaboration: N/A
Resources
Hotop, A., Ferguson, M.(2020, May 14). What are the current recommendations for preventing and treating pediatric migraine?
Iannone, L. F., De Cesaris, F., & Geppetti, P. (2022). Emerging Pharmacological Treatments for Migraine in the Pediatric Population. Life, 12(4), 536. https://doi.org/10.3390/life12040536
Koch, T., Oakley, C.(2018, June 1). Pediatric migraine: diagnostic criteria and treatment. https://www.contemporarypediatrics.com/view/pediatric-migraine-diagnostic-criteria-and-treatment.
Case Study:
C.C. “My head hurts.”
HPI: 7-year-old male presented to clinic reporting a head pain that started three days ago. Aunt, who has custody of him, is also present at visit. He denies recent falls or injuries to head. Denies visual changes, ear pain, sore throat, nasal congestion, fever or chills. He also denies neck pain. He reports not getting headaches before. Aunt reports that she was called by the elementary school because this is his third day going to the school nurse reporting a headache. School nurse has given Tylenol, but it doesn’t seem to help. There hasn’t been a change in diet or weight. He continues to eat and drink well. Aunt reports recently getting custody of her nephew about two weeks ago. He has been having a hard time adjusting to living with her and her kids. He continues to attend the same school.
Past Medical History: Asthma, measles and mumps.
Allergies: Ibuprofen
Medications: Singulair 10 mg PO daily. “Inhaler”-does not remember the name.
Social History: Recently moved in with aunt, uncle & cousins (3 of them: 17, 15, 14). Mother/father deceased. Goes to public school, 2nd grade. No firearms, tobacco, alcohol, illicit drugs in home.
Family History: Mother and father deceased MVA, no medical history. He no siblings. Health Maintenance/Promotion: Will need to obtain records immunizations. Had measle/mumps at the age of 4.
ROS:
General. Denies fever, malaise, fatigue, and weight-loss. Denies night sweats or weight gain. Skin. Denies rashes, lesions, itching, ulcers/growths, bleeding, bruising, dryness or scales. HEENT
Head. Reports headaches and denies dizziness.
Eyes. Denies no current changes in visual acuity, dryness or pain. Ears. Denies ear pain, discharges, tinnitus and hearing loss.
Nose. Denies nasal obstruction, discharges, and bleeds.
Throat. Denies sore throat, hoarseness, dysphagia, and throat pain. Neck. Denies any neck pain.
Cardiovascular. Denies pain to the chest area, palpitations, bruits, and murmurs.
Lungs. Denies cough, wheezing, and shortness of breath. Denies any asthma sx at this time. Gastrointestinal. Denies abdominal pain, burning, acid reflux, nausea, vomiting, bloating, constipation, diarrhea, pain and straining on defecation, no blood in the stool or changes in bowel habits. Denies poor appetite.
Genitourinary. Denies dysuria, nocturia, hematuria, urinary hesitancy or frequency. Musculoskeletal: Denies weakness or joint pain.
Neurologic. Denies any history of seizures. Reports head pain like “squeezing” pain.
Endocrine. Denies temperature intolerance, polydipsia, polyuria, polyphagia, weight loss, weight gain. Psychological. Reports feeling sad at times.
Hematological/Lymphatic. Denies abnormal bruising, bleeding, and no enlarge lymph nodes.
OBJECTIVE DATA
General. A well-dressed, clean male, awake, alert, oriented X 3.
VITAL Signs (VS). Temperature: 99.0 degrees Fahrenheit, temperature route: tympanic. Heart rate: 93 bpm. Respiratory rate: 20 rpm: Blood pressure: 102/78 mm/Hg. Oxygen saturation: 100% on room air. Weight: 42 lbs. Height: 52”.
Skin. Warm and dry to touch, color and turgor good, capillary refill < 3 seconds. No rashes or lesions observed. HEENT: Normocephalic, no tenderness during palpation, no lumps, lesions, or masses, hair thick with even distribution. PERRLA, conjunctiva clear and non-icteric. Tympanic membranes gray and intact with a cone of light noted. Pinna and tragus are non-tender. Nares with no exudate. Turbinate pink and moist. Oropharynx moist, no exudates, tonsils +1. Neck full ROM. Supple, no lymphadenopathy.
Cardiovascular (CV). S1 and S2 are present. No gallops, opening snaps murmurs, or rubs. No pain with palpitation of chest wall.
Respiratory: Unlabored, bilaterally clear to auscultation. Gastrointestinal: Normoactive, bowel sounds heard in all four quadrants. Soft, flat with no distention. Non-tender, and no masses upon palpation. Genitourinary: Bladder is non-distended, no CVA tenderness.
Peripheral vascular: Pink, cap refill < 3 seconds, Extremities warm and dry and without edema. Musculoskeletal. Full range of motion. No crepitus palpated.
Neurologic. Oriented X 3 Normal gait. Good muscle strength and tone. CN II-VII tact. Psych: Flat affect, soft spoken, makes eye contact.
