Assessment And Plan For Mrs N

1. Migraine headaches. 54-year-old woman with migraine headaches since childhood, with a throbbing vascular pattern and frequent nausea and vomiting. Headaches are associated with stress and relieved by sleep and cold compresses. There is no papilledema, and there are no motor or sensory deficits on the neurologic examination. The differential diagnosis includes tension headache, also associated with stress, but there is no relief with massage, and the pain is more throbbing than aching. There are no fever, stiff neck, or focal findings to suggest meningitis, and lifelong recurrent pattern makes subarachnoid hemorrhage unlikely (usually described as "the worst headache of my life"). Plan:

■ Discuss features of migraine vs. tension headaches.

■ Discuss biofeedback and stress management.

■ Advise patient to avoid caffeine, including coffee, colas, and other carbonated beverages.

■ Start NSAIDs for headache, as needed.

■ If needed next visit, begin prophylactic medication, because patient is having more than three migraines per month.

2. Elevated blood pressure. Systolic hypertension with wide cuff is present. May be related to obesity, also to anxiety from first visit. No evidence of endorgan damage to retina or heart.

Plan:

■ Discuss standards for assessing blood pressure.

■ Recheck blood pressure in 1 month, using wide cuff.

■ Review urinalysis.

■ Introduce weight reduction and/or exercise programs (see #4).

3. Cystocele with occasional stress incontinence. Cystocele on pelvic examination, probably related to bladder relaxation. Patient is perimenopausal. Incontinence reported with coughing, suggesting alteration in bladder neck anatomy. No dysuria, fever, flank pain. Not on any contributing medications. Usually involves small amounts of urine, no dribbling, so doubt urge or overflow incontinence.

Plan:

■ Explain cause of stress incontinence.

■ Review urinalysis.

■ Recommend Kegel's exercises.

■ Consider topical estrogen cream to vagina next visit if no improvement.

4. Overweight. Patient 5'2", weighs 143 lbs. BMI is ~26. Plan:

■ Explore diet history, ask patient to keep food intake diary.

■ Explore motivation to lose weight, set target for weight loss by next visit.

■ Schedule visit with dietician.

■ Discuss exercise program, specifically, walking 30 minutes at least three times a week.

5. Family stress. Son-in-law with alcohol problem; daughter and grandchildren seeking refuge in patient's apartment, leading to tensions in these relationships. Patient also has financial constraints. Stress currently situational. No evidence of major depression at present.

Plan:

■ Explore patient's views on strategies to cope with sources of stress.

■ Explore sources of support, including Al-Anon for daughter and financial counseling for patient.

■ Continue to monitor for depression.

6. Occasional musculoskeletal low back pain. Usually with prolonged standing. No history of trauma or motor vehicle accident. Pain does not radiate; no tenderness or motor-sensory deficits on examination. Doubt disc or nerve root compression, trochanteric bursitis, sacroiliitis.

Plan:

■ Review benefits of weight loss and exercises to strengthen low back muscles.

7. Tobacco abuse. 1 pack per day for 36 years. Plan:

■ Check peak flow or FEV-i/FVC on office spirometry.

■ Give strong warning to stop smoking.

■ Offer referral to tobacco cessation program.

■ Offer patch, current treatment to enhance abstinence.

8. Varicose veins, lower extremities. No complaints currently.

9. History of right pyelonephritis, 1982.

10. Ampicillin allergy. Developed rash but no other allergic reaction.

11. Health maintenance. Last Pap smear 1998; has never had a mammogram. Plan:

■ Teach patient breast self-examination; schedule mammogram.

■ Schedule Pap smear next visit.

■ Provide three stool guaiac cards; next visit discuss screening flexible sigmoidoscopy.

■ Suggest dental care for mild gingivitis.

■ Advise patient to move medications and caustic cleaning agents to locked cabinet, if possible, above shoulder height.

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