PBL Case Discussion

• Part One (graded)

Setting: large urban city

Family practice clinic that employs physicians and nurse practitioners

It’s been a fairly easy morning at your family practice site today. You move to the chart holder to get the chart for your next patient, Julia E, who presents with the chief complaint of headache.

HPI: Julia is a 14-year-old young lady who presents with her mother. Julia is sitting on the exam table and is playing on her phone. She does not look up when you enter. Her mother Cathy rises from the chair to greet you. Julia looks up and smiles but returns to looking at the phone until her mother asks her to put the phone away. Julia appears her stated age and is well groomed. Though her mother is present, you pull up your exam stool in front of Julia to ask her why she is her today. “I get headaches, sometimes they last for days. Mom says all the time I spend on the computer and looking at my phone is causing them, but I think it helps distract me from the pain.”

• Part Two

Migraine without aura (G43.0)- defined as a recurrent headaches lasting 4-72 hours, unilateral in location, pulsating in quality, moderate to severe in intensity, aggravated by routine physical activity and associated with nausea and/or photophobia and phonophobia (IHS, 2013).

Rational- Julia meets migraine without aura by having 5 headaches with the following criteria including: headache lasting 4-72 hours, unilateral, pulsating, nausea, and photophobia (TV) (Fenstermacher & Hudson, 2016).

• SOAP Note

Julia, 14 yo, F

S.

CC- headache

HPI- “I get headaches, sometimes they last for days. Mom says all the time I spend on the computer and looking at my phone is causing them, but I think it helps distract me from the pain.” Julia appears her stated age and is well groomed. Julia states that headaches occur one to two times a week and can last 1 to 2 days—puts hands on temple and describes headache as pulsing. She reports pain as 3 out of 5, and is not relieved with Ibuprofen or Naprosyn.