Sally’s Headaches
Purpose:
The purpose of this Assignment is to enhance knowledge the evaluation and
management of acute versus chronic presentation of headache.
Case Study Description:
Sally Jones, 45 years old, presents to the primary care clinic with complaint of a headache. She says the
headache usually comes when she is at work. She works as an administrative assistant for a chief Executive
Officer at a local hospital. The headache is usually generalized and bilateral and most of the intensity of pain
is around the neck or the back of her head. Sally says, “When the pain comes it is like a tight band around
my head.” She says the headaches have been occurring more frequently over the past 30 days. Sally takes
“homeopathic” tea she recently bought on her most recent trip to Mexico to visit her family. She does not
believe in taking medicine for pain because of the side effects.
Directions:
Based on the case study please provide a response to each of the following items:
What are the pertinent subjective findings? What other questions would you ask Sally to gain more
information about her headaches?
Describe the focused physical assessment you will perform on this patient. Provide rationale for
conducting the focused assessment and support with peer-reviewed scholarly references.
Identify the diagnostic studies/tests you will order for this patient (if any). Provide scientific, evidencebased
rationale from a nationally accepted clinical guideline to justify the diagnostic studies/tests you
will order for this patient.
Develop a list of three differential diagnoses for Sally’s symptoms. Prioritize the three differential
diagnoses from the most serious diagnosis to the least significant diagnosis.
What is the most likely diagnosis based on Sally’s history of present illness and chief complaint? Is this
condition acute or chronic-provide your justification?
Develop a comprehensive, holistic treatment plan including pharmacologic and non-pharmacologic
therapies for this patient taking into consideration Sally’s health belief and cultural belief practices.
Discuss the difference in your pharmacologic intervention in acute versus chronic presentation. How will
your treatment change if your patient is an adolescent?
The length of this paper should be 2–3 pages, not including title page and a reference page