00:01
Okay, last case.
00:03
So, we’ve got an older patient here.
00:05
I’ve got a 75-year-old woman.
00:06
She has a one-day history of headache.
00:08
Well, it’s just one of my migraines, she explains.
00:11
Sounds pretty benign.
00:12
Let’s get a little bit more.
00:15
So, she has a long history of
unilateral migraine headaches,
which previously resolved with just a high-dose
non-steroidal anti-inflammatory drugs.
00:24
However, the character of this pain is different.
00:26
It’s very concentrated over her temple specifically
and it's actually tender to palpation there.
00:34
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.
00:44
So, is it, A, just change the type of NSAID she is taking?
Maybe that will make a difference.
00:49
Just reassurance.
00:50
She's right, it’s probably just a recurrent migraine and just continue
with that expectant management that’s been working for a while.
00:56
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.
01:11
Indeed, not every case of acute management just needs reassurance
and it will probably resolve with time because this is unusual.
01:21
New headaches
and different types of headaches
always should raise attention
for potential red flags.
01:27
In this case, you're seeing unilateral temporal-based pain in a
75-year-old woman with the area actually tender to palpation.
01:35
All of that is very concerning for the
diagnosis of…temporal arteritis.
01:41
Very good.
01:42
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.
01:54
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.
02:12
So, she’ll need close follow-up
and an initiation of treatment right away.
02:17
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.
02:27
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.
02:38
Now, what do those conditions include?
I think headache is a high-risk condition.
02:43
So, always pay attention to it.
02:44
Chest pain, while it’s usually
benign, still a high-risk condition.
02:48
New neurological symptoms.
02:50
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.
03:05
Think about stroke,
you think about masses
or other severe CNS disorders.
03:11
Or – and these are often found incidentally – new lesions or
masses in organs such as the skin or the breasts.
03:17
I’ve got this mole and, yeah,
it seems to be growing and changing.
03:20
Then it bleeds and falls off
and then it comes back again.
03:23
The first thing I'm worried about is cancer.
03:25
Now, that's – is it going to be cancer?
Unlikely.
03:29
But the first thing I'm going to worry about is cancer.
03:32
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.
03:43
These are the high-risk conditions just to name a few.
03:46
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.
03:55
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.
04:02
So, hopefully, you found
these cases beneficial.
04:05
Now, we’ll move into the acute care module
and you can see how this plays
out with some real cases.
04:10
Thank you.