Headaches

Chief Complaint: A 50 year-old female presents with headaches.

DOMAIN A: DATA ACQUISITION

+ What are the key components of this patient’s history and physical examination?

Relevant History:

  • What is the onset, timing, location over the cranium, duration, aggravating/alleviating factors, ?radiation, severity of the pain?
  • Was there injury or trauma?
  • Has this ever happened before?
  • Is there any associated nausea, vomiting, diarrhea, vision or hearing changes, weakness, numbness, tingling, bowel/bladder dysfunction, gait dysfunction, memory impairment, abnormal scents, photophobia, phonophobia, or tearing associated with this?
  • Has she had any workup or treatment so far for this problem?
  • Past Medical/Surgical History?
  • Family History?
  • Social History?
  • Functional History? Current functional status?
  • Medications?

Relevant Physical Examination:

  • Vital signs
  • Inspection
  • Palpation
  • Range of motion of cervical spine
  • Cranial nerve examination
  • Manual muscle testing, reflexes, sensation of bilateral upper and lower limbs
  • Special testing: occipital nerve palpation, cervical facet-loading challenge
 

DOMAIN B: PROBLEM SOLVING

The patient is a 50 year-old female with a past medical history of left wrist fracture status post surgical fixation who presents with 6 months of daily intermittent bilateral headaches that are worst in the morning. Her pain is improved with ibuprofen. She denies any vision changes, weakness, numbness, gait dysfunction, or bowel/bladder dysfunction. On exam she is tender to palpation over the cervical paraspinals. Direct palpation of the greater occipital nerves causes pain shooting over the scalp. Her strength, sensation, and reflexes are normal.

+ What is your differential diagnosis for this patient's headaches?

  • Cervicogenic headaches, myofascial pain, occipital neuralgia, cervical spondylosis, cervical facet arthropathy, migraines, tension headaches, cluster headaches, trigeminal neuralgia, intracranial neoplasm, increased intracerebral pressure.

+ Anything else?

  • That is all. Thank you.

+ What workup would you recommend for this patient?

  • No particular workup is indicated at this point in time.
 

DOMAIN C: PATIENT MANAGEMENT

+ How would you manage this patient if cervicogenic headaches were your primary concern?

  • I would recommend physical therapy focused on strength and range of motion of the cervical spine musculature and scapular stabilizer muscles with education on a home exercise program. I would advise over the counter acetaminophen, NSAIDs, ice/heat/massage as needed, stress reduction techniques, proper posture while working.

+ How would you manage this patient for primary headaches that are not cervicogenic?

  • I would consider a dedicated headache medication such as magnesium supplementation, amitriptyline/nortriptyline, gabapentin, or topiramate.
 

The patient returns to your office 2 months later. Her headaches have worsened with your course of treatment. You notice that she turns her head to the left whenever speaking directly with you. She complains of hearing difficulty and notes that her mother also requires hearing aids. She feels a little unsteady with her gait, but attributes this to a history of prior ankle sprains.

+ What are your next steps in management, and why?

  • I would order an MRI of the brain and cervical spine with contrast. I am concerned about a possible pathologic intracranial process that may involve the cervical spine, given the patient’s worsening headaches with vision changes, hearing changes, and gait dysfunction. I would counsel the patient on why I am ordering the imaging and CC her primary care physician on the note or send a copy of my note of the physician is outside my health system. I would ensure all questions are answered and would ask if the patient is agreeable to the plan.

+ Your next steps lead to the following:

  • MRI brain with contrast is positive for an abnormal enhancing intracerebral mass.

+ How would you manage this patient?

  • I would call the patient, inform her of the results, and offer my next steps in the plan. I would offer my sympathetic condolences and reassure her that I will be here to support her every step of the way as we work to treat this problem. I would counsel that her headaches and other concerning symptoms are likely the result of this mass identified on the MRI scan of her brain. I would recommend consultations with neurosurgery, oncology, and radiation oncology for a treatment plan.
 

DOMAIN D: SYSTEMS-BASED PRACTICE

The patient undergoes surgical resection of a large meningioma without complications. She is medically stable and not requiring medications. A course of radiation therapy is being arranged. Physical and occupational therapy evaluations demonstrate that the patient is performing below her baseline level of function and is not safe for home discharge alone. She does not have any family or friends in town who would be able to provide full-time supervision. You are consulted as the rehabilitation physician for this patient.

+ What are your recommendations for her?

  • Given that she lacks medical complexity, she will likely not qualify for inpatient rehabilitation, despite her functional deficits. She is medically stable and not requiring medications. She will not require daily physician supervision and active management of medical comorbidities while she is rehabilitated. Furthermore, it may present an undue challenge to coordinate her radiation therapy schedule with her demanding inpatient rehabilitation schedule. I would recommend skilled nursing facility placement so that she can rehabilitate with the support of trained nursing staff along with physical and occupational therapy without the need for close medical supervision.
 

During her skilled nursing facility stay she attends a scheduled virtual follow-up visit with you. She notes that she has resided at this facility for 2 weeks and only sees her nurse once daily; she is otherwise left alone in her room all day. You note a cluttered, dirty countertop in her vicinity.

+ How would you handle this situation?

  • If I had a concern for her immediate safety or life-threatening neglect, I would call 9-1-1. In her case I would call the facility and ask to speak to the nursing home director and attending physician on staff. I would call a social work consultation for further recommendations. I would strongly consider calling state or national nursing home abuse agencies on her behalf. I would inform her if she has any concern for her safety or wellbeing, please dial 9-1-1, and I would ask if she has a phone nearby that she can use safely, given her decreased functional status. I would consider contacting social work to help initiate a transfer to a different facility.
 

DOMAIN E: INTERPERSONAL AND COMMUNICATION SKILLS

The patient completes her rehabilitation at another facility and is discharged home in modified independent functional status.  This is the role-playing portion of our encounter.  I will play the role as the patient.

Patient: “Doctor, I feel like my memory is gone, and I have a hard time ge-getting the right wards--words out.”

+ What is your response?

  • What you have been through and continue to battle is incredibly difficult, and I commend you for your strength and your efforts as you take on this challenge. Thank you for sharing this with me. We need to work to help you further and do what we can to improve your memory and language skills. I would like you to consider being evaluated by a speech/language therapist, and also consider counseling for what you are going through, as it is certainly not an easy task, though you are meeting the challenge formidably. We can also consider neurology or psychiatry consultations to help identify other factors that may improve your memory, including possible medication options. Does that sound like an acceptable plan? Please let me know if you have any concerns about this plan, or any other questions or thoughts today.