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16 février Thursdays Will Be Case Presentation Days!I have decided that Thursdays, here at the-Future-Dr-Cara Show, will be case presentation days! While this will bore some of you to tears, I'm hoping that it will provide some insight for pre-meds into the interconnection between history taking and physical examinations. Or it will totally turn them off of medicine.
Oh, and we're going with Thursdays due to the fact that they are ECM days, and the information from my case will still be fresh in my mind (which is slowly being filled with brain anatomy and physiology!)
Today's topic: acute headaches. The American Family Physician magazine, published by the Association of American Family Physicians, published a great article regarding the evaluation of acute adult headaches, and states that most headaches can be of one or two etiologies: primary or secondary. Primary headaches are acute headaches with no known "organic" cause, meaning that if you were to do a CT of someone with a primary headache, you wouldn't see anything abnormal. In this category, we have migraines, cluster and tension headaches. These headaches, while painful, are not a sign of a more serious condition. Secondary headaches, on the other hand, are a sign of something bad! These are generally caused by such lovely things as hypertension, aneurism, meningitis, and the licencing board favorite: subarachnoid hemmorage! However, physicians can't just send anyone to radiology for a cat scan or MRI, so finding out all the information you can about the headache is crucial to a proper diagnosis. This is where good history taking and physical examination come into play.
For the history, it is important to find out the OPQRST's of the complaint: Onset, Pain, Quality/Quantity, Radiation, Severity and Time. Also, location (unilateral or bilateral), comorbid conditions, age of patient, medication history and family history are also very imporant. For example: a patient comes into the office complaining of a history of a headache around one of their eyes. The patient has been getting these headaches more frequently over the past two weeks. The patient is also recovering from a viral cold, and has been experiencing rhinorrhea (a runny nose). In this case, the headache is most likely a cluster headache. Another example: a 55 year old man comes in complaining of a 6 month history of a headache. The man states that it started out as a mild, ache that would come and go, and he could ignore, but has become more painful and constant. In this case, due to the man's age, and the type of pain and frequency of the headache, it is more likely that this is a secondary headache, and is possibly due to a mass in the brain.
For today's ECM session, my "patient" was a 40 year old female, complaining of a 6 month history of headache that is mild in the morning and worsens throughout the day. She works as an assistant interior designer in a busy buisness, that requires her to attend shows, commute between offices, and deal with multiple clients. Her pain, on a scale of 1 to 10 (10 being the most severe pain she has ever felt) is rated a 4 or 5. She states her pain is generally on the top of her head. Comorbidity: she is being treated for hypothyroidism. Family history: both parents alive, father is hypertensive and diabetic, mother has arthritis. Current medications: thyroid hormone replacement therapy, tylenol for the headache - occasionally takes vitamin C, iron and B complex vitamins. Non-smoker, social drinker. She denies having a fever, allergies, watery eyes, head trauma, nausea, vomiting, neck pain or stiffness, photophobia, or phonophobia.
General apperance: well nourished, well groomed caucasian female. Vitals: BP 122/64, P 72, R 16. Neuro: PEERL, alert and orientated X4, no abnormalities in function of cranial nerves II - XII. No pain on scalp palpitation, no aphasia or other vocalization abnormailities. Upper motor shows symetrical strength.
(Note: this is as far as we got - we're only allotted 15 minutes for our encounter, and, trust me, as a medical newbie, you never have quite enough time.)
Diagnosis: Tension headache. Her headache lacks a sudden onset, the pain is bilateral in the occipital-frontal area, mild to moderate, and worsens as the day progresses. Her vitals are within normal limits, and she has no pain over her temporal arteries.
Treatment: NSAIDs, a hot or cold pack, and possibly some stress reduction techniques.
For something like a headache, every detail is important, as it often rules out or indicates something more serious. Then again, as we go along, we keep finding how every single detail is important, and nothing should be overlooked.
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