4MB Clinical Problem-Solving.ppt

4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine Presenting Complaint: 40-yr-old ♀ with headache History of Presenting Complaint How recent in onset? Abrupt onset? How frequent? Episodic or constant? How long lasting? Intensity of pain? Quality of pain? Site of pain? Radiation? Eye pain? Aura? Photophobia? Phonophobia? Associated vomiting? Diurnal variation? Snoring? Neck stiffness? Trigger factors? Aggravating factors? Relieving factors? Family history? What does the patient do during headache? What medication used? Physical Examination Fever? Pulse/BP Neck stiffness? Purpuric rash? Pupils? Neurologic exam GCS score Scalp tenderness? Examine eardrum Thickened temporal arteries? Fundoscopy – papilloedema? Sinus tenderness? Cervical tenderness/ROM? Obese? Facial plethora? 38-yr-old ♀ with headache, facial pain and dry cough.Give the diagnosis. 20-yr-old ♀ with headache, fever and neck stiffness.Give the diagnosis. 70-yr-old ♀ with a painful red eye and headache.Give the diagnosis. Investigations FBC ESR Capillary blood glucose Plasma Alkaline phosphatase Arterial blood gas Skull radiograph Cervical spine radiographs CT Brain Lumbar puncture CSF manometry MR angiogram Temporal artery biopsy Sinus radiographs Sleep studies 65-yr-old ♂ with headache, deafness and bone pain.Give the diagnosis. Differential Diagnosis Tension headache Cluster headache Trauma Vascular Migraine Subarachnoid haemorrhage Arteriovenous malformation Subdural haematoma Hypertensive encephalopathy Temporal arteritis Skull disease Sinusitis Skull fracture Mastoiditis Paget’s disease of bone Acute mountain sickness Medications Nitrates Sildenafil OCP Metabolic Sepsis CO2 retention Hypoxia Obstructive sleep apnoea Hypoglycaemia Alcohol withdrawal Raised intracranial pressure Cerebral tumour Meningitis Otitis media Acute angle-closure glaucoma Hyperviscosity 32-yr-old obese ♀ with headache. Normal CT Brain.Give the diagnosis. 68-y