PART 1 and 2 – Case Study # 3 PART 1:Table 1. Dermatologic Differential of Commo

PART 1 and 2 – Case Study # 3
PART 1:Table 1. Dermatologic Differential of Common Skin Lesions and Rashes
Name
Cause
Signs/Symptoms
Diagnostics
Treatment
Concerns
Rocky Mountain Spotted Fever
Tick bite Rickettsia rickettsii
Fever, chills, severe headache, n/v, photophobia, myalgia, conjunctival injection, arthralgia; 2-5 days after onset – rash (petechiae) starts on hands/feet to trunk (palmar rash)
Antibody titers to rickettsia
Punch biopsy
CBC, LFT, CSF
Doxycycline 100mg BID for 7-14 days – can be fatal if not started on treatment within 8 days. Remove tick by grasping closest to skin and apply steady upward pressure
Can be fatal (3-9%)
Highest in southeastern/south central regions of US Most common Apr – Sept
Erythema Migrans (Lyme disease) Meningococcemia
Tick bite Borrelia burgdorferi (Scar and Simonsen, 2018)
A typical rash occurs 1-2 weeks after the tick bite (erythema migrans) often on the axilla, groin, and waistline. Central clearing of the rash with burning/itching may occur. Constitutional symptoms include fevers, headache, myalgia, fatigue, arthralgia, and rarely nausea/vomiting. Other uncommon symptoms include the following: facial palsy, lymphadenopathy, stiff neck, and radiculoneuritis (Scar and Simonsen, 2018).
Screening test for serum antibodies to B. Burgdorferi using sensitive enzyme immunoassay immunofluorescent antibody assay.
Western blot test
CBC, ESR, EKG (Scar and Simonsen, 2018)
Doxycycline 100 mg orally BID for 10 days for adults and children above 8 years. Patients under 8 should be given amoxicillin 50 mg/kg/day TID. Removal of ticks (Scar and SImonsen, 2018)
Meningitis and neurologic complications can occur if not treated properly (Scar and Simonsen, 2018)
Varicella / Zoster
Varicella Zoster virus which causes chickenpox and herpes zoster or shingles (Folusakin and Sandeep, 2018)
Prodromal symptoms – aching muscles, nausea, decreased appetite, headache followed by rash, oral sores, malaise, and fever. Rash with small red dots on the face, torso, and extremities. The lesions then progress to bumps, blisters, and pustules (Folusakin and Sandeep, 2018).
Herpes zoster or shingles causes pain with stabbing quality and tingling. Unilateral vesicular rash along dermatome in thoracic or lumbar areas. Begins as erythema then popular lesions that form into vesicles and scabs (Folusakin and Sandeep, 2018).
Thorough physical examination, PCR assay, and antibody titer (Folusakin and Sandeep, 2018)
Antivirals within 72 hours such as Famiciclovir or Valacyclovir. Pain management and prevention of secondary infections or spreading the infection to others (Folusakin and Sandeep, 2018)
High risk with non-immune pregnant women and immunocompromised individuals. Varicella pneumonia has a 10-30% fatality in adults (Folusakin and Sandeep, 2018).
Malignant Melanoma
Caused by malignant melanocytes related to family history, personal characteristics (blue eyes, fair or red hair, pale complexion), sun exposure, atypical mole syndrome, and low socioeconomic status (Heistein & Acharya, 2020)
Changing characteristics of or the presence of a new mole that are asymmetric, have an irregular border, variations in color, diameter greater than 6 mm, and elevated surface (Heistein & Acharya, 2020)
Excisional biopsy, CBC, CMP, lactate dehydrogenase, lymph node biopsy, CT scan, MRI, and PET scan may be indicated to determine metastasis (Heistein & Acharya, 2020)
Surgery with wide local excision with lymph node biopsy and elective node dissection, chemotherapy, radiation therapy, and biological therapy (interferon and interleukin therapy) (Heistein & Acharya, 2020)
Complications can occur with delayed diagnosis such as secondary infections, lymphedema, local recurrence, and metastasis (Heistein & Acharya, 2020)
Basal Cell Carcinoma
Exposure to UV light – UVB and UVA (McDaniel et al., 2020)
Shiny, pink or flesh-colored papule with telangiectasia and rolled borders, small crusts, and non-healing wounds or scabs (McDaniel et al., 2020)
Shave, punch or excisional biopsy, dermoscopy, and complete skin evaluation (McDaniel et al., 2020)
Surgical removal with cosmetic correction – MOHS surgery, radiation, photodynamic therapy, and cryosurgery (McDaniel et al., 2020)
Poor prognosis in areas of high risk such as nose, ears, and periorificial areas which may reoccur and become more aggressive (McDaniel et al., 2020)
Actinic Keratosis
Effects of UV radiation on the keratinocytes over a lifetime of sun exposure (Marques and Chen, 2020)
Irritated, scaly rash with pruritus, tenderness, burning and stinging commonly found on areas exposed to the sun such as the face, ears, back of the neck, and forearms (Marques and Chen, 2020)
Thorough skin examination and palpation for scaly and rough texture of lesions.
Dermoscopy or biopsy (Marques and Chen, 2020)
Cryotherapy, curettage, or surgical excision
Field-directed therapies such as topical chemotherapy medications or immunomodulators, photodynamic therapy, or laser resurfacing
Fluorouracil cream applied for 3 weeks
Aldara cream twice weekly for 16 weeks (Marques and Chen, 2020)
Treatment includes adverse effects such as pain, inflammation, and scarring.
Recurrence or transformation to squamous cell carcinoma (Marques and Chen, 2020)
Erythema Multiforme (Stevens-Johnson syndrome)
Commonly due to Herpes Simplex virus type 1 and 2, and Mycoplasma Pneumoniae
Medications such as antibiotics, antituberculosis agents, and antipyretics (Hafsi and Badri, 2020)
Fever, general unease, arthralgia, and joint swelling prior to the eruption
Rounded lesions with three concentric circles and well-defined borders are found on the palms, back of the hands and feet, and extended faces of the limbs
Mucosal lesions of the mouth, genitals, and ocular mucous membranes that turn into painful erosions (Hafsi and Badri, 2020)
Skin biopsy of the lesion center, CBC, CMP, LFTs (Hafsi and Badri, 2020)
Topical treatment antiseptic for bullous lesions and anesthetics
Triamcinolone 0.1% topically to affected areas BID or oral steroids – Prednisone 40-60 mg daily for 5-10 days (Hafsi and Badri, 2020)
Severe cases may require hospitalization to monitor or manage dehydration and infection.
Long-term risk of developing ocular sequelae leading to blindness (Hafsi and Badri, 2020)
Table 2. Differential Diagnoses of Eye Emergencies
Name
Cause
Signs/Symptoms
Diagnostics
Treatment
Concerns
Corneal Abrasion
Trauma, foreign body, incorrect use of contact lenses
Acute onset severe eye pain with tearing. Reports feeling of foreign body sensation
Eye exam with Fluorescein dye
Flush eye with sterile normal saline. Evert eyelid to look for foreign body. Topical antibiotic trimethoprim-polymyxin B (Polytrim),Ciprofloxacin (Ciloxan), Ofloxacin (Ocuflox) to affected eye 3-5 days.
Do not patch eye.
Contact Lens-Related Keratitis – acute onset red eye, blurred vision, watery eyes, photophobia, foreign body sensation
Hordeolum (Stye)
Staphylococcus bacteria infects the eyelash hair follicle (Bragg et al., 2023)
Painful, red, and swollen eyelid without previous trauma or foreign body.
Pain is localized to the affected area and does not cause ocular pain or affect eye movement (Bragg et al., 2023)
Based on clinical findings and examination (Bragg et al., 2023)
Warm compresses and massaging the affected area to express purulent drainage.
Lid scrubs with saline or mild tear-free shampoo to clear debri and prevent clogging of ducts.
Large lesions may require erythromycin ophthalmic ointment four times daily or ciprofloxacin ointment three times daily.
Recurrent hordeolum may require oral Keflex. (Bragg et al., 2023)
Infections with S. aureus are contagious and caution should be taken to prevent the spread of infection (Bragg et al., 2023)
Chalazion
Inflammation and obstruction of sebaceous glands of the eyelid (Jordan and Beier, 2020)
Painless swelling on the eyelid, inflammation, and impaired vision.
Palpable, non-tender nodule on the eyelid (Jordan and Beier, 2020)
Based on clinical findings and examination (Jordan and Beier, 2020)
Warm compresses to the eye 2-4 times daily, lid massage, and baby shampoo.
If symptoms persist for more than a month an ophthalmologist may be needed.
If an infection is present doxycycline 100 mg twice daily for 10 days (Jordan and Beier, 2020)
An untreated chalazion can lead to preceptal cellulitis.
The risk of eye impairment increases with lesions greater than 5 mm and excision should be considered (Jordan and Beier, 2020)
Pinguecula
Caused by exposure to sunlight or UV light, trauma, wind, dust, sand, and contact lenses (Somnath and Tripathy, 2021)
Grey, white-yellow elevated round mass on bulbar conjunctiva that is otherwise asymptomatic (Somnath and Tripathy, 2021)
Clinical findings,
Slit-lamp exam or optical coherence tomography angiography (Somnath and Tripathy, 2021)
Treatment is not typically required.
Symptom management may include artificial tears for dryness and cold compresses to reduce inflammation.
Surgical excision for cosmetic reasons or argon laser photocoagulation (Somnath and Tripathy, 2021)
Complications include recurrence, progression to pterygium, and pigmentary changes after excision (Somnath and Tripathy, 2021)
Pterygium
Exposure to UV sunlight, dry and dusty conditions (Sarkar and Tripathy, 2021)
Irritation of the eye, lacrimation, foreign body sensation, and changes in vision (Sarkar and Tripathy, 2021)
Comprehensive ocular exam with visual acuity, extraocular movements, and anterior segment evaluation.
Schirmer’s test
Slit-lamp examination
Fluorescein stain (Sarkar and Tripathy, 2021)
Protecting the eyes from UV light with the use of sunglasses, hats and limiting time in the sun.
Artificial tears
Topical corticosteroid – fluorometholone ophthalmic 0.1% drops in the affected eye 2-4 times daily
Surgery (Sarkar and Tripathy, 2021)
Complications after surgery include graft edema, epithelial defects, graft necrosis, subconjunctival hematoma, and fibrosis (Sarkar and Tripathy, 2021)
Subconjunctival Hemorrhage
Trauma, foreign body, contact lens use, eye surgery, hypertension, diabetes, and hyperlipidemia (Doshi and Noohani, 2020)
Painless, acute, demarcated area of extravasated blood beneath the eye (Doshi and Noohani, 2020)
Eye exam with fluorescein stain (Doshi and Noohani, 2020)
Ice packs and artificial tears to relieve symptoms.
Typically resolves within 1-2 weeks without treatment if no underlying factors are present (Doshi and Noohani, 2020)
Can be an indicator of an underlying disorder such as coagulopathy, asthma, or severe orbital trauma (Doshi and Noohani, 2020)
Primary Open-Angle Glaucoma
Increased resistance to drainage in the trabecular meshwork, causes increased pressure in the eye, leading to optic nerve damage and visual loss. Can be related to genetics, age, diabetes, and hypertension (Mahabadi et al., 2020)
Asymptomatic in the early stages then, patients complain of tunnel vision when nerve fibers are affected.
Peripheral vision loss, notching of optic nerve cup, cup-to-disk ratio >0.5, and increased intraocular pressure (Mahabadi et al., 2020)
Tonometry, gonioscopy, direct ophthalmoscopy, slit-lamp biomicroscopy, visual field testing, and optical coherence tomography (Mahabadi et al., 2020)
Topical eye drops – Latanoprost ophthalmic 0.005% one drop daily into the affected eye at night
Timolol ophthalmic 0.25 or 0.5% one drop into the affected eye twice daily
Laser trabeculoplasty
Diode laser cyclophotocoagulation
Cyclocryotherapy (Mahabadi et al., 2020)
If not treated promptly or properly, it may lead to blindness. 13.5% of individuals develop painless blindness (Mahabadi et al., 2020)
Macular Degeneration
Macula gets thinner with age or abnormal blood vessels grow in the back of the eye damaging the macula.
Caused by older age, hereditary, and smoking (National Eye Institute, 2021)
Blurred vision, difficulty seeing with dim light, seeing crooked images, blurry area near center of vision, and distorted vision of colors (National Eye Institute, 2021)
Comprehensive dilated eye exam, Amsler grid, optical coherence tomography, and Fluorescein angiography (National Eye Institute, 2021)
Early stages require monitoring for worsening in vision and progression to later stages.
With intermediate MD antioxidant and mineral supplementation can be initiated – Vitamin C 500 mg, Vitamin E 400 U, beta-carotene 15 mg, zinc 80 mg, and copper 2 mg.
No treatment for late stages (National Eye Institute, 2021)
With progressive stages of MD, living with blindness or poor vision can be difficult. Essential to provide patients with support and education to live with vision loss (National Eye Institute, 2021)
Table 3. Differential Diagnoses of Common Headaches
Name
Signs/Symptoms
Aggravating Factors
Acute Treatment
Prophylaxis
Migraine Without Aura
Throbbing pain behind one eye, photophobia, N/V phonophobia, last 4-72 hr.
Red wine, MSG, aspartame, menstruation, stress
Ice pack on forehead, rest in dark quiet room
Triptans, Tigan suppositorie
TCAs
Episodic migraine (<14 days per month) Beta-blockers Migraine With Aura Prodromal phase – occurs 24-48 hours before the onset of headache – irritability, depression, neck stiffness, and cravings. Aura phase – flickering light, blind spots in vision, tinnitus, tingling, numbness, or paresthesia. Headache phase – Throbbing/pulsatile pain unilateral or bilateral, nausea/vomiting, photophobia, phonophobia Postdromal phase – transient headaches, tiredness and exhaustion (Shankar Kikkeri and Nagalli, 2023) Stress, bright lights or overstimulation of sounds, aged cheese, nitrates, MSG, weather changes, caffeine, medications, too much or too little sleep, and menstruation (Shankar Kikkeri and Nagalli, 2023) Ice pack on forehead, lying down in a quiet dark room to remove triggers, NSAIDs, triptans, antiemetics, and ergots (Shankar Kikkeri and Nagalli, 2023) Beta-blockers like metoprolol or propranolol Anti-depressants like amitriptyline or venlafaxine Anti-convulsants like valproate or topiramate Calcium channel blockers like verapamil or flunarizine (Shankar Kikkeri and Nagalli, 2023) Trigeminal Neuralgia (CN V) Unilateral, sharp, stabbing, intense pain in the face, lasting up to 2 minutes (Lambru et al., 2021) Facial or oral mechanical stimulation including light touch, talking, chewing, brushing teeth, drinking, and shaving (Lambru et al., 2021) Topical lidocaine or local anesthetic injections if pain is severe If medications are not effective, microvascular decompression or ablative surgery (Lambru et al., 2021) Anti-convulsant medications – Carbamazapine 200 mg/day in 1-2 doses Gabapentin 300 mg daily Baclofen 10 mg three time daily (Lambru et al., 2021) Cluster Repeated attacks of unilateral pain are reported as 10/10 excruciating pain. Occur in clusters and then stop for several months. Lacrimation, rhinorrhea, and partial Horner syndrome Agitation, restlessness (Kandel and Mandiga, 2020) Television, alcohol, hot weather, stress, use of nitroglycerin, sexual activity, and glares (Kandel and Mandiga, 2020) 100% oxygen therapy Intranasal sumatriptan 20 mg or intranasal zolmitriptan 5 mg Intranasal lidocaine (Kandel and Mandiga, 2020) Verapamil, glucocorticoids, lithium, valproic acid, gabapentin, topiramate, melatonin Suboccipital blockade (Kandel and Mandiga, 2020) Muscle Tension Generalized frontal or occipital head pain that is non-pulsatile and constricting. Worsens at nighttime and unrelated to activity Shoulder or neck muscle tightness, and sleep disturbances (Shah and Hameed, 2020) Stress, eye strain, muscular contractions of the shoulder, neck, scalp or jaw (Shah and Hameed, 2020) NSAIDs – Ibuprofen 400 mg, Aspirin 325 mg or Tylenol 1000 mg (Shah and Hameed, 2020) TCAs – amitriptyline 10-25 mg daily and titrate Physical therapy, improving posture, relaxation techniques (Shah and Hameed, 2020) PART 2: Case Study #3A 48-year-old male presents with a two-month history of nighttime headaches that are becoming more frequent. The pain awakens him at night. He has no other somatic complaints and no other significant medical history. SOAP Note – Case Study # 3 48-year-old male SUBJECTIVE: Chief Complaint: Patient with complaints of a “two-month history of headaches that awaken him at night”. HPI: O – When did the headaches begin? L – Where is the headache located, and does it radiate to anywhere else such as the neck or shoulders? D – How long has the headache been going on for? C – What does the pain feel like? Is it throbbing, dull, constricting, stabbing, pulsatile, etc.? A – Is there anything that makes the pain worse? R – Is there anything that makes the pain better? Have you tried doing or taking anything to help alleviate the pain? T – What were you doing when the headaches began? S – What would you rate the pain from 1-10? Past Medical History: Do you have any other medical history? Past Surgical History: Have you had any surgeries in the past? Family History: Do you have any family history of migraines, cluster headaches, or tension headaches? Medications: Are you currently taking any prescribed or over-the-counter medications or vitamins and herbal supplements? Allergies: Do you have any allergies to foods, medications, or latex? Immunizations: Are your immunizations up to date? Have you received the COVID and Flu vaccines? Social History: Are you currently experiencing any stress at work or at home? Do you use any drugs, alcohol or other substances? Tell me about your work and everyday activities. Review of Systems: General – Reports awakening at night due to headaches. Are you exhibiting any weakness, tiredness, or fatigue? Eyes – Are you exhibiting any eye strain or pain around the eyes/ forehead? Any changes in vision or blurred vision? Ears/Nose/Throat – Are you exhibiting a runny nose, eye tearing, or sinus pain? Respiratory – Are you exhibiting any difficulty breathing or congestion? Gastrointestinal – Are you exhibiting any nausea, vomiting, and changes in appetite or cravings? Musculoskeletal – Are you having any neck or shoulder pain, stiffness, or muscle tightness? Are you having any difficulty carrying out daily activities? Neurological – Reports a 2-month period of headaches. Have you experienced headaches before? If so, do they feel like your current headaches? Any dizziness or vertigo? Are you experiencing any sensitivity to light or noise? OBJECTIVE: Vital signs HEENT – Asses the head for any trauma. Asses eyes with a vision exam and assessing cranial nerves. Assess for any lacrimation or rhinorrhea. Assess the nares for any congestion and patency. Respiratory – Auscultate the lungs for any respiratory abnormalities. Gastrointestinal – Auscultate the bowel sounds. Musculoskeletal – Assess for ROM in the neck and arms, for any stiffness, pain, or muscle tightness. Assess balance and gait. Neurological – Assess the cranial nerves. Assess for numbness, tingling, or paresthesia. Assess balance. ASSESSMENT (DIAGNOSIS): Differential Diagnosis Cluster headachePertinent positives – a headache for 2 months Pertinent negativesDenies any restlessness, agitation, lacrimation, rhinorrhea, and partial Horner syndrome Denies unilateral pain that is sharp or stabbing in nature Denies any remission of headaches in the last 2 months Cluster headaches cause severe throbbing or sharp pain that lasts anywhere from 15 minutes to 3 hours, and occurs for a duration of 6-12 weeks during acute attacks (May, 2023). They occur with frequent clusters in attacks and remissions without headaches for weeks or months (May, 2023). They often cause autonomic symptoms such as ptosis, miosis, lacrimation, rhinorrhea, and nasal congestion (May, 2023). The patient identified in this case study is not exhibiting any autonomic symptoms which are diagnostic criteria for cluster headaches. Migraine headachePertinent positives – prolonged headache Pertinent negativesDenies nausea or vomiting Denies decreased ability in functioning Denies worsening of headaches with activity Denies sensitivity to light or noise (photophobia or phonophobia) Denies irritability, food cravings, depression Denies genetic components for migraine headaches Migraine headaches occur in several phases – prodromal, aura, headache, and postdromal. During the prodromal phase patients experience depression, irritability, food cravings, and neck stiffness (Cutrer, 2023). Patients with migraines may or may not experience auras. The aura phase causes tinnitus, tingling, blind spots in vision, numbness, or paresthesia (Cutrer, 2023). During the headache phase patients experience throbbing/pulsatile pain, nausea and vomiting, and phonobia and photophobia (Cutrer, 2023). The last phase of migraines is characterized by tiredness and exhaustion (Cutrer, 2023). The patient identified in this case study is not exhibiting any nausea/vomiting, loss of daily function, phonophobia, or photophobia – all of which are criteria for diagnosis. Therefore, this is not an appropriate diagnosis. Working Diagnosis Tension headache, unspecified, not intractable - ICD 10 Code – G44.209 (ICD-10 Code for Tension-Type Headache, Unspecified, Not Intractable- G44.209- Codify by AAPC, n.d.) Pertinent positivesHeadache unrelated to activity Headache worsens at night A 2-month period of headaches Pertinent negativesNo nausea or vomiting No photophobia or phonophobia No rhinorrhea, lacrimation, or sinus congestion PLAN: Diagnostics Based on clinical findings CBC/ CMP to determine any underlying cause If attacks are progressive, may need CT, MRI or lumbar puncture to rule out other more serious conditions Pharmacologic intervention Aspirin 325/1000 mg orally every 4-6 hours during acute attacks or Acetaminophen 325-1000 mg orally every 4- 6 hours or Ibuprofen 400-800 mg orally every 4-6 hours If the above medications do not work - Amitryptiline 10 mg orally daily at bedtime, then increase by 10 mg/day every week; maximum dose 100 mg/day Non-pharmacologic intervention Relaxation training Cognitive behavioral therapy Physical therapy to improve posture and prevent neck or shoulder strain Acupunture Patient education Educate the patient on stress relief and decreasing triggers of headache Educate the patient on preventing eye strain if this is a concern Educate the patient on the importance of a regular sleep cycle and getting adequate rest Educate the patient on proper meals and refraining from skipping meals Educate the patient about s/s of bleeding due to Aspirin therapy Educate the patient to take medications as prescribed and never to take more or less Educate patient to maintain a headache diary to monitor consistency and progression Referrals/ Follow-Up Follow up with the patient in 3-4 weeks to determine improvement in headaches and the effectiveness of the current treatment regimen. If symptoms are unimproved, he will be referred to a neurologist for further testing. Health MaintenanceEnsure the patient has completed colon screening given his age Dyslipidemia screening HTN screening Diabetes screening Immunizations for Flu, COVID, TdAP, Hepatitis B If you chose case study 3, complete the below Differentials Table. Differential Signs/Symptoms Gold Standard Diagnostics Gold Standard Treatment Ex: Temporal arteritis (giant cell arteritis/GCA) Unilateral pain, temporal area with scalp tenderness, skin over artery is indurated, tender, warm and reddened; amaurosis fugax (temporary blindness). Medical urgency – refer to ED or Ophthalmologist High dose steroids * Dose and route of administration of glucocorticoids for newly diagnosed GCA varies depending on whether patient presents with or without threatened or established visual loss at diagnosis. 1. Cluster headache Repeated attacks of excruciating unilateral pain, lacrimation, rhinorrhea, partial Horner syndrome, agitation and restlessness (Kandel and Mandiga, 2020) Based on clinical findings in relation to the International Classification of Headache Disorders Acute treatment: High flow oxygen Intranasal sumatriptan 20 mg or intranasal zolmitriptan 5 mg Intranasal lidocaine (Kandel and Mandiga, 2020) Prophylaxis: Amitriptyline 10 mg daily and increase dosage to a max of 100 mg/day 2. Migraine headache Prodromal phase – occurs 24-48 hours before the onset of headache – irritability, depression, neck stiffness, and cravings. Aura phase – flickering light, blind spots in vision, tinnitus, tingling, numbness, or paresthesia. Headache phase – Throbbing/pulsatile pain unilateral or bilateral, nausea/vomiting, photophobia, phonophobia Postdromal phase – transient headaches, tiredness and exhaustion (Shankar Kikkeri and Nagalli, 2023) Based on clinical findings Acute Treatment: Ice pack on forehead, lying down in a quiet dark room to remove triggers, NSAIDs, triptans, antiemetics, and ergots (Shankar Kikkeri and Nagalli, 2023) Prophylaxis: Beta-blockers like metoprolol or propranolol Anti-depressants like amitriptyline or venlafaxine Anti-convulsants like valproate or topiramate Calcium channel blockers like verapamil or flunarizine (Shankar Kikkeri and Nagalli, 2023) 3. Medication Overuse headache Duration of pain more than 3 months, comorbidities, pain causing difficulty performing daily activities, joint swelling and tenderness, associated somatic symptoms – nausea, difficulty concentrating, memory issues (Garza and Schwedt, 2021) Based on clinical findings, course of headache and history of medication use (Garza and Schwedt, 2021) Discontinuation of overused medication and initiation of prophylactic treatment (Garza and Schwedt, 2021) 4. Sphenoid sinusitis Throbbing pain and pressure around the eyeball worsened by bending forward, earache, neck pain, or ache at the top of the head or temples, post nasal drip, congestion, sore throat (Shah and Hameed, 2020) Nasal endoscopy, CT, MRI (Shah and Hameed, 2020) Antibiotics and intranasal corticosteroids, nasal sprays, decongestants, steam inhalation and analgesics (Shah and Hameed, 2020) 5. Pituitary Tumor Chronic and worsening headaches, anorexia, nausea, vomiting, fatigue, gynecomastia, loss of libido, diaphoresis, weakness, decreased visual acuity (Pituitary Adenomas (Tumors) Description and Treatment Options, 2019) Blood tests and urine tests to identify hormone levels, MRI, CT, vision testing (Pituitary Adenomas (Tumors) Description and Treatment Options, 2019) Depending on the location and size of the tumor may require surgery, radiation, and medications to address hormonal imbalance (Pituitary Adenomas (Tumors) Description and Treatment Options, 2019)