Julia 14y Case Study

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Julia 14y, female
S: SUBJECTIVE
Chief Complaint (CC): “Headache”
History of present illness (HPI): Julia is a 14-year-old young lady who presents with her mother. 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. No aura. Sometimes they upset her stomach, but she has never vomited. Sleep helps sometimes. The only thing that seems to work is distraction, so she plays Minecraft. The TV hurts her eyes. She likes to read but can’t when she has headaches. No trigger identified. She wears contacts, last visit to eye doctor last month, prescription was updated and she states she sees
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The migraine is characterized by episodes of moderate-to-severe, pulsating, unilateral headache, lasting for 4–72 h with sensitivity to light and sound, nausea and vomiting (Diener, 2013). The patient must have at least two of: 1) nausea during the attack, 2) light sensitivity during the attack; 3) some of the attacks interfere with their activities (NCG, 2012). The migraine headache is often exacerbated by activity. Julia has headache pain that last for days. Julia has three of the three qualifying criteria points including nausea, eye pain with watching television, and inability to enjoy reading related to headache pain. Julia also describes her pain as lasting days at least one to two times a week, pulsating, and temporal.
(G47.0) INSOMNIA- the inability to fall asleep and stay asleep, have continuous sleep without waking during the night, and/ or waking up early (Chung, 2012). Adolescents are affected by many changes that influence sleep patterns including biological, personal, and psychosocial variations (Chung, 2012). Julia is 14 year old with complaints of headache and change of sleeping
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Julia should maintain the sleep diary for at least 15 days to help evaluate her sleep patterns.
• Be sure that no electronics are shining light while sleeping (George, 2013)
• Sleep hygiene practices- make sure bed is comfortable and room is dark (George, 2013)
Further diagnostic teaching:
• None needed at this time (George, 2013)
Education:
• Julia should go to bed at the same time every night, go to bed when sleepy, refrain from playing video games prior to bedtime, no caffeinated foods or beverages prior to sleep, no chocolate prior to bedtime (George, 2013).
• Try listening to calming music and mediating (George, 2013)
• Allow Julia to sleep in on weekends (George, 2013)
Referral:
• None needed at this time (George, 2013)
Follow-up:
• 2 weeks to review the sleep diary and evaluate further if sleep does not improve (George,

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