Chapter 30 Head and neck pain in the elderly

Case 30.1

History

Jane is a 70-year-old retired teacher. She presents with a 3–4 month history of episodes of pain between her scapulae, in addition to the left side of her neck. The pain usually occurs when she is climbing more than one flight of stairs, or walking on an incline. After resting for a couple of minutes, the pain subsides. She says that it feels like ‘tight muscles’. Moving her neck does not bring on or exacerbate the pain. There are no other symptoms accompanying the pain.

She has four children who live scattered throughout the country, and was widowed 3 years ago. She is quite active doing volunteer work at a large city hospital, 4 half days a week. She has been a vegetarian for the last 2 years.

Occasionally when Jane is rushing, she can feel her heart beating and even hear it throbbing in her ears. She has noticed that she is generally weaker than she used to be, but believes that it is probably ‘an age thing’.

Jane says that she has trouble sleeping some nights and lately she has noticed herself becoming quite irritable with other people.

Two years ago she had an episode of shingles, around the level of her left lower ribs. There has been no history of trauma. She states that she is mildly hypertensive, and is on a low dose of prazosin hydrochloride. She has no problems with either urination or defecation. She went through menopause at the age of 53. She was prescribed hormones for a period of 4 years to deal with her various symptoms.

Jane’s father died of a heart attack, and her mother from a stroke. She has smoked approximately 10 cigarettes a day for 50 years.

Questions

1. List the possible causes of Jane’s neck and interscapular pain. Based only on the history, do you think that her symptoms are more likely to have a mechanical or a non-mechanical cause? Justify your answer.

2. What type of drug is prazosin hydrochloride?

3. What type of ‘hormones’ do you think Jane was referring to?

4. What parts of her history may be indicative of anxiety?

5. What do you need to examine in this patient?

Physical examination

General	Jane is a thin woman, in no obvious distress. There is slight pallor of her conjunctiva
Vitals	•Pulse rate/min	86, strong
	•Respiratory rate/min	16
	•Blood pressure mm Hg	135/90
	•Temperature (degrees C)	36.5
HEENT	Unremarkable
Neck	• Unremarkable • Cervical spine has full range of motion • Tightness of scalenes and upper trapezius
Chest	• Apex beat shifted slightly to the left • Heart sounds normal • No murmurs • Lung fields clear
Abdomen	Soft, non-tender, no masses
Limbs	• Bilateral shoulder ROM (range of motion) full and pain free • Lower limbs: Peripheral pulses normal, colour and temperature normal
Back	Unremarkable
Neurological	Unremarkable

Questions

6. What information can you obtain from these findings? Can you narrow your differential diagnosis?

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