Okay, last case.
So, we’ve got an older patient here.
I’ve got a 75-year-old woman.
She has a one-day history of headache.
Well, it’s just one of my migraines, she explains.
Sounds pretty benign.
Let’s get a little bit more.
So, she has a long history of
unilateral migraine headaches,
which previously resolved with just a high-dose
non-steroidal anti-inflammatory drugs.
However, the character of this pain is different.
It’s very concentrated over her temple specifically
and it's actually tender to palpation there.
So, just with that limited history alone,
what's the next best step in the
management for this patient?
And again, you could pause and
think about this for a second.
So, is it, A, just change the type of NSAID she is taking?
Maybe that will make a difference.
She's right, it’s probably just a recurrent migraine and just continue
with that expectant management that’s been working for a while.
Do you initiate maybe a new drug, like a
triptane instead of giving her an NSAID?
Maybe that’ll be more effective
for a migraine headache?
Or, D, do we send her to the laboratory
immediately and we also initiate corticosteroids?
So, this one is to throw you off.
Indeed, not every case of acute management just needs reassurance
and it will probably resolve with time because this is unusual.
and different types of headaches
always should raise attention
for potential red flags.
In this case, you're seeing unilateral temporal-based pain in a
75-year-old woman with the area actually tender to palpation.
All of that is very concerning for the
diagnosis of…temporal arteritis.
So, temporal arteritis can have severe complications,
particularly in terms of risk of
thrombosis and ischemia immediately,
so she could lose her vision,
she can have a stroke.
Therefore, immediate laboratory evaluation
for simple things like a Sed rate and a CBC
for the potential for temporal arteritis
and she should not leave your clinic
without a prescription for corticosteroids
because the application of corticosteroids can
dramatically reduce that risk of complication.
So, she’ll need close follow-up
and an initiation of treatment right away.
So, this is just an example,
but I thought it was a keen example to give you
an idea that not every case can be managed
just with expectant management and reassurance.
But, certainly, I think for USMLE exam
and the way I think about patient care,
the answer many times,
it's not every answer,
and so the trick for you
is to watch for high-risk conditions.
Now, what do those conditions include?
I think headache is a high-risk condition.
So, always pay attention to it.
Chest pain, while it’s usually
benign, still a high-risk condition.
New neurological symptoms.
This isn’t the patient with diabetes for 20 years,
who has bilateral tingling in the feet,
but I’m talking about somebody who has
monocular blindness or a left facial droop,
something new going on that's acute.
Think about stroke,
you think about masses
or other severe CNS disorders.
Or – and these are often found incidentally – new lesions or
masses in organs such as the skin or the breasts.
I’ve got this mole and, yeah,
it seems to be growing and changing.
Then it bleeds and falls off
and then it comes back again.
The first thing I'm worried about is cancer.
Now, that's – is it going to be cancer?
But the first thing I'm going to worry about is cancer.
And anytime somebody comes in with a –
I feel a new mass in my breast,
particularly if they’re over 50 and particularly
if they are higher risk for breast cancer
because of a family history or something like that.
These are the high-risk conditions just to name a few.
But some of the more common ones that we see
should alert you to the fact that
you might need to really go
and perform a more thorough workup here.
You may need to order advanced therapy
for this patient right from the get-go,
not everything can just be
a wait-and-see approach.
So, hopefully, you found
these cases beneficial.
Now, we’ll move into the acute care module
and you can see how this plays
out with some real cases.