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Course # 90213 • Diagnosing and Managing Headaches

CASE STUDY 1

Mrs. T is an African American woman, 68 years of age, with a past medical history significant for type 2 diabetes, hypertension, hyperlipidemia, osteoarthritis, and coronary artery disease. She presents to the clinic with a chief complaint of "headache." Mrs. T describes the headache as a dull pain that has been intermittent over the past several weeks. It is not localized to any particular area, but rather seems to be more diffuse. It does not radiate to the neck, back, or any other parts of the body. It first started about a month ago.

She has taken ibuprofen and aspirin sporadically with some relief. As the headache has been persistent over the past few weeks, she thought it was important to come in and be evaluated. She states that she has been looking up information on headaches on various health websites and she now thinks she needs a "brain scan." She has no prior history or family history of migraines; she does report a history of what she considers to be some tension-type headaches in the past few years. She believes these are due to stress at work, as they usually resolve within a day with relaxation, rest, and ibuprofen. She has never been evaluated for these episodes. The patient also remarks that over the past several days she has occasionally felt a little dizzy and light-headed, but those symptoms have largely resolved. She denies any confusion or loss of consciousness, but her daughter, who accompanies her to the clinic, states that Mrs. T had an episode about a week ago where she seemed disoriented in the morning for approximately an hour. According to the daughter, "Lately, Mom sometimes seems in a fog."

Upon further questioning, Mrs. T denies any fever, nausea, or vomiting. She denies depression or weight loss. She has not had visual disturbances. She does not recall any environmental exposures. Her current medications include metformin, lisinopril, simvastatin, and celecoxib. She remarks that her job is going quite well, and she does not feel particularly stressed from work. She works as a senior account manager at a consulting firm.

She has not had any change in medications and does not use any herbs or supplements. She drinks two cups of coffee a day, and there has been no recent change in her coffee consumption. There is neither family history of headaches nor family history of cancer. Both parents died of heart disease. She does note that she recently tripped and fell outside (almost a month ago) while playing with her grandson, but denies any serious consequences from the fall other than a sore left wrist. She denies any residual weakness. She notes that she does not feel "quite 100%" but does not feel confused or "in a fog."

On physical exam, Mrs. T's blood pressure is 135/82 mm Hg, heart rate is 78 BPM, respirations are 18/minute, temperature is 98 degrees, height is 5'5", and weight is 135 lbs. The physical exam is largely unremarkable. There are no masses appreciated, no petechiae noted, no sinus pain or tenderness, no scalp tenderness, and no neck stiffness. There are no visual defects and no focal neurologic deficits with the exception of minimal decrease in muscle strength in lower extremities bilaterally. She scored a 26 (maximum score: 30) on the Mini-Mental Status Exam, with some difficulty remembering three objects as well as performing serial 7s.

Given the patient's age and the fact that the headache has been persistent, a clinician should order a more extensive work-up. The patient seems to be dismissive of the minor fall, but this should be explored further. Although it would be easy to attribute this headache complaint to a tension-type headache, secondary causes should be excluded.

Mrs. T's laboratory tests are as follows:

Na 138; Cl 100; K 4.0; CO2 26; BUN 15; Creatinine 0.9; Glucose 125; Hgb 12.5; Hct 38; WBCs 5,000; Platelets 200,000; TSH 0.9; T3 120; ALT 30; AST 32; Alk phos 70; Total bili 1.0; LDH 120; GGT 22; ESR 35

EKG: normal sinus rhythm at 78 BPM; left axis deviation; evidence of old anterior infarct. No acute changes.

Upon further history taking, it becomes clear that Mrs. T did experience a significant fall a few weeks ago, even though she minimized it when mentioning it. Sequelae are present. Therefore, a contrast-enhanced CT should be ordered.

The CT scan demonstrated hypodense areas in both hemispheres, consistent with subdural hematoma. There was no evidence of mass effect. The subdural hematoma is likely a result of the fall approximately one month earlier. Mrs. T was admitted to the hospital for observation and given diuretics and anticonvulsants. Her clinical course was good with resolution of the hematoma without the need for surgery.

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