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A 59-year-old woman comes to your office because she is concerned that she might have a brain tumor. She has had a fairly severe headache for the last 3 weeks (she rates it as an 8 on a scale from 1-10). She describes the pain as constant, occasionally throbbing but mostly a dull ache, and localized to the right side of her head. She thinks the pain is worse at night, especially when she lies with that side of her head on the pillow. She has had no nausea, vomiting, photophobia, or other visual disturbances. She has had headaches before, but they were mostly occipital and frontal, which she attributed to "stress," and they were relieved with acetaminophen. Her medical history is significant for hypertension, which is controlled with hydrochlorothiazide, and "arthritis" of her neck, shoulders, and hips for which she takes ibuprofen when she feels stiff and achy. On physical examination, her temperature is 100.4°F, heart rate 88 bpm, blood pressure 126/75 mmHg, and respiratory rate 12 breaths per minute. Her visual acuity is normal, visual fields are intact, and her fundus-copic examination is significant for arteriolar narrowing but no papilledema or hemorrhage. She has moderate tenderness over the right side of her head but no obvious scalp lesions. Her chest is clear, her heart rhythm is regular, with normal S, and S, but an S4 gallop. Abdominal examination is benign. She has no focal deficits on neurologic examination. She has no joint swelling or deformity but is tender to palpation over her shoulders, hips, and thighs.
^ What is the most likely diagnosis?
♦ Which serum test will confirm the diagnosis?
ANSWERS TO CASE 50: Headache/Temporal Arteritis
Summary: A 59-year-old woman complains of a 3-week history of severe right-side headaches that are worse at night, when she lies with that side of her head on the pillow. Her medical history is significant for hypertension and "arthritis" of her neck, shoulders, and hips, for which she lakes ibuprofen. She has a temperature 100.4°F and normal neurologic and eye examinations. She has moderate tenderness over the right side of her head but no obvious scalp lesions.
♦ Most likely diagnosis: Temporal arteritis (TA). ^ Test to confirm diagnosis: Erythrocyte sedimentation rate (ESR).
1. Be familiar with the clinical features that help to distinguish a benign headache from one representing a serious underlying illness.
2. Know the clinical features and diagnostic tests for TA.
3. Know the clinical features of migraine and cluster headaches and of subarachnoid hemorrhage.
Although headaches are a very common complaint, this patient has features that are of greater concern: older age of onset, abrupt onset and severe intensity, and dissimilarity to previous milder headaches. These are three of the nine factors of concern for significant underlying pathology outlined in Table 50-1.
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