You are on a day shift on D-side, and the nurses bring back
a15 year old male complaining of a headache. He is there with his parents, and he explains that he was at school when
the headache developed. He denies trauma
or inciting factors. He explains that
while at school with the headache, he felt very weak and pre-syncopal. There was no true loss of consciousness, but
he describes feeling lightheaded and feeling “close to passing out”. At that point he went to the nurses office,
where his family was contacted. He has
not been sick recently, denying fevers, chills, chest pain, shortness of
breath, URI symptoms, nausea, vomiting, diarrhea, dysuria, rash or joint pains. He does explain that he missed breakfast that
morning, and didn’t eat lunch during the day “because he was busy”. He does recall drinking a little bit of water
earlier in the day.
On exam, his vital signs are BP 112/74, HR 102, RR 16, O2
sat 100% RA. He has an entirely normal
physical exam with no focal neurologic findings (including cranial nerves, motor,
sensory to light touch, cerebellar and gait testing).
You decide to get an ECG, hydrate him and give
ibuprofen. After a generous fluid bolus
and NSAID therapy, he reports his headache is feeling better. His ECG demonstrates only NSR, HR 98. You decide to talk to him more about his
skipping meals today, and he explains that he seems to have lost the taste for
a variety of foods. Specifically, he
names strawberries, burgers, ice cream and cookies as foods he used to enjoy, but
don’t taste good anymore. His mother is
able to name a number of other foods that he has “lost the taste for”. She notes that he has lost at least 5 pounds
since his last physical 6 months ago. At this point, your patient’s headache is resolving.
Questions for you:
Have something to add? More information you need? Questions aren't complete enough? share your thoughts by clicking on "comments" below. Come back later in the week for the Hot Seat commentary by Julia LaJoie.
SO, if the headache is getting better, its obviously not a bleed - PHEW. Worst case scenario resolved.
ReplyDeleteSO now, this taste thing is weird. W.E.I.R.D. In my vague memories of brain antomy, the taste center is kind of small, kind of tiny. I don't think we can see that spot on a head CT, so I would like to get an MRI of his brain and see if there is anything there (is the family nice? pleasant? cooperative? thankful? - all bad prognostic factors for brain tumors)
SO, now, when do I want this MRI? Well, I don't want to send this kid out into the world without a defined day or time for the exam - in fact, I'd prefer the child is admitted and gets this MRI tomorrow (assuming we can't get it today)... If neuro balks, I'm going to play up the headache in combination with the loss of taste and advise that he be admitted to follow headaches.
Well, it appears that this patient has 'hypogeusia.' (I learned a new word, yay!) This could go along with migraines, or with a whole host of other things, including depression, oral infections, medications, etc. As someone who has been burned recently by a patient whose headache got better and had a normal head CT, I think I would like this patient to have an MRI in the near future. If I could arrange this as an outpatient, with the help of neuro or the PMD, I would feel a lot better.
ReplyDeleteI'm a little worried by his subjective loss of appetite, decreased POs and recent weight loss. Is he anorexic and is this deliberate weight loss? He's a bit tachycardic, possibly indicating dehydation or medication abuse to lose weight (? amphetamines). Also, hyperthyroidism may cause tachycardia and weight loss. I'd add TFTs and a urine drug screen to his labs. If he has a brain lesion/tumor causing a headache, then it should be big enough for a CT to see it -- not sure he needs an MRI. But I'd much rather prefer to do a fundoscopic exam in the ED. If normal, I wouldn't obtain neuroimaging urgently. BTW, I believe hypothalamic tumors can present with loss of smell, which is on the differential of hypoguesia. Did we check confrontational visual fields?
ReplyDeleteHi Sonny sorry it has taken me a while to get to this but I had this little thing called a Triathlon to do yesterday ;). Now this is a case that is easy to blow off because 1. the headache started later in the day, not the kind that wakes you up in the early morning hours which is concerning for increased ICP. 2. It is getting better and there are no focal neurological deficits. But there are a few things I like to test in all pre-syncopal or syncopal patients. What were the Orthostatic VS? Also, what is the urine dip? In this patient I would expect to see ketones in the urine and if they are not there I would go on to test glucose and electrolytes. I know you said the neurological exam was negative but when the patient and family mention a loss of weight and a change in taste sensation I would worry about a pituitary adenoma. I would go back a check peripheral vision very carefully on my exam. The heart rate is still fast after the bolus so a TSH to screen for hyperthyroidism, especially in light of the weight loss. You give the option of checking electrolytes but unless you have blood drawn before the bolus this might be misleading because you will miss hyponatremia. If I have that pre-bolus blood I'd probably send a BMP and a TSH. I wouldn't make the family wait for the TSH but I'd call the PMD and arrange for follow-up with the PMD and Neurology if the weight loss and taste changes persist or the TSH returns high as he probably needs an MRI. Finally, I'd admonish him to stay well hydrated and eat small frequent meals.
ReplyDeleteOh yes, while they are dipping the urine for ketones they should probably do a urine drug screen as well.
ReplyDelete