Table of Contents
Common Questions
Chat with CodyMD
Cody's Chat with Patient
Cody's AI Summary
Top 3 AI Diagnosis List
Review by Dr Albert DiPiero
Resource Center
Testimonials
Share this Case Study
Case Study
Meet your host
Albert DiPiero, MD MPH FACP
I am a co-founder and the Chief Medical Officer at CodyMD and your host for this edition of Cody Grand Rounds. I have been a practicing physician and faculty member at medical schools for over 26 years.
About The AI Doctor Case Study
CodyMD is a partnership between Human Doctors and AI Doctors. Cody is an AI Doctor who helps thousands of people every day. At each Cody Grand Rounds, I select a real case and review it with Cody, the AI Doctor.
Each case is based on a real patient but has been modified to maintain privacy and to emphasize certain teaching points.
Common Questions
What are the common symptoms of a migraine headache?
How long do migraine headaches usually last?
What triggers migraine headaches?
How are migraines diagnosed?
What treatments are available for migraines?
What are the symptoms of sinusitis?
How to differentiate between a tension headache and a migraine?
Chat with CodyMD
Click the button below to initiate a conversation with CodyMD, your AI Doctor.
Cody's Chat with Patient
Below is a conversation transcript between the patient and our AI Doctor CodyMd.
Cody, the AI Doctor
Good to meet you! I understand you've been experiencing some discomfort lately. Can we focus on the nausea, dizziness, and headache you're experiencing today?
Patient
Yes, that's right. It's been pretty tough.
Cody, the AI Doctor
My goal is to provide you with an accurate assessment and plan. Let’s start with when these symptoms began. How long have you been experiencing the nausea, dizziness, and headache?
Patient
It's been about three days now.
Cody, the AI Doctor
Based on your recollection, did these symptoms start suddenly, or did they come on gradually?
Patient
They came on gradually. It started with just a bit of a dull headache, and then the nausea and dizziness followed.
Cody, the AI Doctor
Can you tell me more about the headache? Where exactly is the pain located, and how would you describe it?
Patient
It's located on the right side, around my eye area. It's not sharp, more like a dull, throbbing pain. I'd say it's moderately severe.
Cody, the AI Doctor
On a scale of 1 to 10, with 1 being no pain and 10 being the worst pain imaginable, how would you rate it?
Patient
I would rate it around a 6 or 7.
Cody, the AI Doctor
Have you noticed any sensitivity to noise or light during these episodes?
Patient
Yes, actually. Both noise and light seem to make it worse.
Cody, the AI Doctor
I see. Have you experienced any other symptoms, such as visual disturbances, nausea upon standing, or any ear-related problems?
Patient
No visual disturbances, but the dizziness does feel a bit worse when I stand up. I haven't noticed any issues with my ears.
Cody, the AI Doctor
Have you had any recent illnesses or changes in your health before these symptoms started?
Patient
I had a cold with some congestion about a week ago, but no other significant changes.
Cody, the AI Doctor
Thank you for that information. Do you have any history of migraines, chronic headaches, or any other chronic illnesses?
Patient
No, I don't have any history of migraines or chronic illnesses, and I've never experienced a headache like this before.
Cody, the AI Doctor
Understood. Are you currently taking any medications, either over-the-counter or prescribed?
Patient
Just some ibuprofen for the headache, but it doesn’t seem to help much.
Cody, the AI Doctor
It's important to note the medication use. How about your lifestyle? Do you consume alcohol, caffeine, or use tobacco or recreational drugs?
Patient
I drink coffee every morning, but I don't smoke or use recreational drugs. I do drink alcohol occasionally, maybe a couple of times a month.
Cody, the AI Doctor
Does anyone in your family have a history of migraines, headaches, or similar issues?
Patient
My mom used to get migraines, but I haven’t had anything like this before.
Cody, the AI Doctor
I appreciate your responses. Is there anything else you've noticed or feel might be relevant to your symptoms that we haven't covered?
Patient
Not really. It's just the headache, nausea, and dizziness that are really bothering me.
Cody's AI Summary
- You are a 27-year-old man with a right-sided headache with nausea and dizziness for three days.
- The headache is around the right eye.
- You rate the headache pain as a 6 or 7 out of 10.
- You have also experienced some sensitivity to noise and light.
- You report no history of chronic illness or previous similar symptoms.
- You had a cold with congestion one week ago.
- There are no visual disturbances (aura) or ear-related problems reported.
- You have no significant smoking or drug use history, and no other medical problems
- Your family history includes migraines in your mother.
Top 3 AI Diagnosis List
Based on the information and conversations with Cody, we have prepared a top 3 AI Diagnosis List.
1. Migraine( 50 % probability)
A neurological condition often characterized by severe, throbbing headaches, often on one side of the head, and associated with sensitivity to light and sound, as well as nausea.
2. Sinusitis(30 % probability)
Inflammation of the sinuses commonly following a cold or upper respiratory infection, which can cause headaches, facial pain, and congestion.
3. Tension headache(20 % probability)
A common type of headache characterized by a dull, aching head pain and pressure around the forehead or back of the head, but can sometimes present with nausea.
Review by Dr Albert DiPiero
Dr. Albert DiPiero
In reviewing this case, the patient's symptoms suggest a few potential diagnoses.
1. Migraine(75% probability)
The headache's right-sided, throbbing nature, along with noise and light sensitivity, strongly suggests a migraine, particularly given the patient's family history of migraines.
2. Sinusitis(15% probability)
The recent history of a cold with congestion brings sinusitis into consideration. Sinusitis can lead to headaches and facial pain, and the headache's location near the eye is consistent with sinus-related pain. However, the absence of nasal symptoms and facial tenderness makes this less likely.
3. Tension Headache(10% probability)
A tension headache is possible but less likely given the location and characteristics of the pain and the presence of significant nausea and light/noise sensitivity. Tension headaches typically present with a bilateral, band-like sensation rather than a focused periorbital headache.
Next Steps for Evaluation
Detailed Medical History and Examination: A comprehensive physical examination of the head, neck, and neurological system is crucial to rule out other potential causes and underlying conditions impacting the patient's symptoms.
Symptom Diary: Keeping a headache diary to track the frequency, duration, and triggers of headaches will help in better diagnosing and managing the condition.
Imaging Studies (if needed): If the physical or neurological exam reveals abnormalities or if symptoms persist or worsen, or did not respond quickly to a trial of medications, an MRI or CT scan of the head might be required to rule out serious underlying conditions such as tumors or structural abnormalities.
Potential Treatment Modalities
Medication Treatments:
For Migraines: Triptans (e.g., Sumatriptan) can be effective for acute treatment. Anti-nausea medications like metoclopramide can also provide relief.
For Sinusitis: Antibiotics might be prescribed if a bacterial infection is suspected, along with nasal corticosteroids and decongestants for symptomatic relief.
For Tension Headaches: NSAIDs like ibuprofen or acetaminophen may be used. Muscle relaxants can also be considered if there is significant muscle tension.
Lifestyle Changes:
Hydration & Diet: Ensure adequate hydration and regular, balanced meals to help manage headaches.
Sleep Hygiene: Establishing a consistent sleep schedule with adequate rest can be beneficial.
Stress Management: Techniques such as yoga, meditation, or cognitive-behavioral therapy can help in reducing stress, which is a common headache trigger.
Avoidance of Suspected Triggers:
Caffeine Management: Moderating caffeine intake can help, especially if the patient is sensitive to it.
Light and Noise Sensitivity: Use of sunglasses, earplugs, or a quiet, dark room during an attack can provide relief.
Resource Center
Testimonials
It gave me the best response possible and suggested simple self care treatment options which I'm in favor with. It has a to the point interface and brief answer for better understanding.
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