Common Problems in Ambulatory Internal Medicine (Case 2: A Problem Set of Five Common Cases)

Madelaine R. Saldivar MD, MPH and M. Susan Burke MD

CASE 1

A 35-Year-Old Woman with Headache

The patient is a 35-year-old healthy woman who comes to the office with daily headache and dizziness for 6 weeks. Her only medication is an oral contraceptive. Her exam is unremarkable except for a blood pressure of 130/90 mm Hg and body mass index of 30.

Differential Diagnosis

Primary Headache	Secondary Headache
Migraine	Medication side effect
Tension	Inflammatory: systemic lupus erythematosus (SLE), temporal arteritis
	Infectious: meningitis, sinusitis
	Intracranial mass or hemorrhage

Speaking Intelligently

When we see this patient in the office, our first task is to determine whether she is well enough to continue her evaluation in the office. Signs and symptoms that warrant consideration for immediate transfer to the emergency department (ED) for emergent evaluation include sudden-onset severe headache, focal neurologic complaints, projectile vomiting, and severe hypertension. Headaches are common, and 90% of the time there will be a benign cause. A gradual onset of symptoms and a precipitating event, such as increased stress or a recent viral illness, make us consider benign causes.

PATIENT CARE

Clinical Thinking

• A careful history is the best tool to narrow the differential diagnosis.

• Migraine and tension-type headaches are the most common causes of cephalgia, but don’t forget to look for warning signs that point to a more ominous cause.

• If there are no warning signs to serious disease, initial empirical treatment for one of these disorders is recommended.

• Radiologic studies are reserved for persistent or changed symptoms.

• Counseling on modifying environmental and lifestyle triggers is important.

History

Making sure there are no concerning symptoms is important. These are:

• Age over 50 years

• Accompanying systemic symptoms

• Headache brought on by exertion

• Visual changes or focal neurologic deficits

• Sudden onset of the worst headache of one’s life

• Severe hypertension

• Change in the pattern of chronic headache

• Projectile vomiting

Physical Examination

• Concentrate on vital signs (fever, hypertension, or hypotension) and the neurologic exam, including a funduscopic exam, looking for papilledema and/or hemorrhages. Any abnormality should prompt immediate transfer to the ED for acute management and workup.

Tests for Consideration

• Computed tomography (CT) head	$334
• Magnetic resonance imaging (MRI) brain	$534
• Complete blood count (CBC)	$11
• Basic metabolic profile (BMP)	$12
• Serum human chorionic gonadotropin (hCG)	$21
• Lumbar puncture	$272
• Urinalysis	$4
• Antinuclear antibody (ANA)	$16
• Erythrocyte sedimentation rate (ESR)	$4

Clinical Entities

Medical Knowledge

Migraine Headache
Pφ	The pathophysiology of headaches is not well understood. However, experts agree that there are multiple factors that contribute to development of a headache: 1. Increased neuroexcitation with cortical spreading depression 2. Vascular dilation
TP	Migraine can be distinguished from other types of primary headaches by its characteristics.

Dx	Making the diagnosis is based on history and physical. Secondary causes and warning signs of more serious causes should not be present.
Tx	All of the headaches described above respond to acute management with analgesics. Acetaminophen and ibuprofen have been shown to be effective as first-line medications for tension and migraine headaches. Remove headache triggers—alcohol, chocolate, sweeteners, caffeine, nitrites, hormonal medications, stress, and schedule changes or sleep deprivation. If migraine headaches persist, consideration should be given to headache prophylaxis with daily suppressive therapy (e.g., amitriptyline, β-blocker, or topiramate). See Cecil Essentials 119.

Secondary headaches are discussed in Chapter 64, Headache.

a. Temporal arteritis: It is a large-vessel vasculitis that affects the temporal artery, usually bilaterally. Associated symptoms include temporal headache, jaw claudication, and vision changes. It should be considered in any patient presenting with typical complaints, especially in patients over the age of 50 years. It is a medical emergency that requires treatment with immediate steroids. Diagnosis is made by temporal artery biopsy.

b. Subarachnoid hemorrhage: This is usually due to trauma or rupture of a cerebral artery aneurysm. Typical symptoms include sudden onset of an excruciating headache with no history of headache in the past. The diagnosis should not be delayed. Emergent CT scan is warranted. Treatment is usually expectant management and blood pressure control in an intensive-care setting.

Practice-Based Learning and Improvement: Evidence-Based Medicine

Title
Practice parameter: evidence-based guidelines for migraine headache; report of the Quality Standards Subcommittee of the American Academy of Neurology

Authors
Silberstein SD

Problem
What are evidence-based approaches to treating migraine headache?

Intervention
Analgesic medications and prophylactic medications

Quality of evidence
Systematic review of class I studies for treatment, class I, II, and III studies for diagnosis and neuroimaging utility

Outcome/effect
Migraine is a chronic condition with episodic attacks that affects 18% of women and 6% of men. Treat acute attacks rapidly. Consider prophylactic medications to reduce disability, frequency, and severity associated with attacks.

Historical significance
Migraine headaches are common and are disabling at a significant cost to society due to lost work productivity.

CASE 2

A 43-Year-Old Man with Back Pain

The patient is a 43-year-old truck driver who presents with right lower back pain (LBP) that started about a week ago when he lifted a heavy load at work. He stopped working and has been resting ever since. He tried acetaminophen, which did not help; however, his brother’s oxycodone with acetaminophen does provide him with relief.

Differential Diagnosis

Mechanical/nonspecific	Disk herniation	Compression fracture
Degenerative spine disorders	Spinal stenosis

Speaking Intelligently

Back pain is the second most common symptom-related reason for which patients present to the doctor. The vast majority of low back pain is due to mechanical or nonspecific causes and does not require imaging. The goal of evaluation is to identify those patients needing urgent attention by looking for signs and symptoms (red flags) suggesting an underlying condition that may be more serious and by determining who may need urgent surgical evaluation. We also evaluate for psychosocial factors (yellow flags), because they are stronger predictors of LBP outcomes than either physical examination findings or severity and duration of pain.

• Evaluate for red flag symptoms that suggest more ominous causes requiring immediate evaluation.

• Red flags include:

• Recent significant trauma, mild trauma with age over 50 years

• Unexplained weight loss

• Unexplained fever or recent urinary tract infection

• Immunosuppression

• Injection drug use

• Osteoporosis

• Prolonged use of glucocorticoids

• Age over 70 years

• Progressive motor or sensory deficit

• Duration longer than 6 weeks

• History of cancer

• Saddle anesthesia, bilateral sciatica/weakness, urinary or fecal difficulties

Physical Examination

• Observe patient walking and changing position.

• Inspect and palpate the back and spine, noting any asymmetry, bruising, scars, deviation from the normal lordosis, or step-off between vertebrae.

• Check reflexes and sensation.

• Test for manual strength in both legs. Can the person walk on his or her heels (L5) and toes (S1)?

• Know how to do a proper straight-leg raising (SLR) test. With the patient supine, lift the leg up. For a positive SLR, the patient should note pain down the posterior or lateral leg below the knee (not just in the back) at less than 70 degrees of hip flexion. A herniated disk correlates with a positive SLR at a lower degree of elevation, is aggravated by ankle dorsiflexion, and is relieved with knee flexion. A crossover SLR produces pain in the affected leg when the unaffected side is raised and is more specific for nerve irritation.

Clinical Entities

Medical Knowledge

Mechanical Low Back Pain/Nonspecific
Pφ	Complex and multifactorial; can involve any lumbar spine elements including bones, ligaments, tendons, disks, muscle, and nerve. Onset may be from an acute event or cumulative trauma. Most common presentation of back pain. May be divided into acute (<4 weeks), subacute (4–12 weeks), or chronic (>12 weeks).
TP	Pain can be hard for patient to localize because of the small cortical region dedicated to the back.
Dx	Clinical diagnosis; imaging is indicated only if red flags are present or symptoms persist. More than 90% of symptomatic lumbar disk herniations occur at the L4/L5 and L5/S1 levels.
Tx	Most mechanical LBP resolves within 6 weeks. If it persists or worsens (or both), consider imaging. For acute pain use heat, nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and/or spinal manipulation. For chronic pain, use exercise, heat, NSAIDs, tricyclic antidepressants, and/or spinal manipulation. May also consider acupuncture or cognitive behavioral therapy. See Cecil Essentials 119.

Disk Herniation
Pφ	Herniation is thought to result from a defect in the annulus fibrosus, most likely due to excessive stress applied to the disk, with extrusion of material from the nucleus pulposus. Herniation most often occurs on the posterior or posterolateral aspect of the disk.
TP	Dermatomal distribution of sensory deficit, motor weakness, or hyporeflexia.
Dx	Clinical exam including SLR test. MRI is indicated only if weakness or incontinence is present.
Tx	Initial treatment is with analgesics and/or steroids. Surgery is reserved for patients with refractory pain or with evidence of motor deficits. Outcomes are similar at 5 years for patients treated either way.