Today we are going to continue with our analysis of the Till Death Do Us Part case ((Sa MM, Relvas A, Leandro S. Till Death Do Us Part. Journal of Clinical Case Reports 2016;6(4):1-.)) from a medical mindset. We will be looking through the stages of the history, the examination, and the investigations, thinking through it from the perspective of a medical student.

As this post continues from the previous, it would be advantageous for you to have read that post. If you missed that previous post in this series, please have a look at the original by going to this page.

History Continued

So far, we’ve only looked at the first line… this post we will be working through the rest of the case much more quickly. I will not be speaking to the case following the diagnosis and treatment, but the article
((Sa MM, Relvas A, Leandro S. Till Death Do Us Part. Journal of Clinical Case Reports 2016;6(4):1-.)) provides a decent explanation of the importance of the family doctor in the support of the patient and their family. I stated in the previous post that this report was only one page long, so if you haven’t read through it yet, I do recommend having a look through. Through excluding discussion of the ongoing support, I will just be considering the cues, hypotheses and mechanisms of the actual disease state. As this case has limited details presented, I will be considering what could be meant by the included statements.

The case moves on from the first line to say that the patient was admitted and consulted for headache-like symptoms. The use of the term admitted is of interest, as the term admission is specifically used for a patient that has been taken on as an inpatient, generally from presenting to a hospital, but clinics or other treatment facilities that take on inpatients can also be included. What this generally excludes from being the case though is that the patient has just attended their Family Medicine doctor (FD) or more commonly, at least in Australia, their General Practitioner (GP). They may have attended their GP or FD and received a referral to a hospital that has resulted in hospital admission, but this seems unlikely in this case. The patient likely presented with a headache with a 3-day history along with a runny nose and/or facial tenderness (pain on palpation/touching). This, in isolation, would not warrant immediate referral to secondary care (hospital and specialist care) and would be expected to be an infection in the sinuses, known as a sinus headache.
((Sa MM, Relvas A, Leandro S. Till Death Do Us Part. Journal of Clinical Case Reports 2016;6(4):1-.))

As such, it seems that the patient likely presented to the emergency department with these symptoms. This would be a rare occurrence in Australia, most likely to occur in an extremely severe case, particularly after hours. In contrast, in the United States of America (USA), presentation to the emergency department or hospital clinics for minor concerns is common enough due to their healthcare model based on health insurance provided (primarily) through employers. Emergency department and hospital clinic presentation in the USA for milder concerns is (from my understanding) much more common among the unemployed and those of poorer socioeconomic status. However, this paper comes from Portugal, whose healthcare model I am unaware of, and so I am unable to comment on what their healthcare system is like and whether this is an uncommon presentation or not within that setting.

As to the headache itself, migraine headaches last from four to seventy-two hours. As such, a migraine headache does fit the stated timeframe. That said, migraines are typically pulsating pain and are associated with nausea (and vomiting), photophobia (light avoidance due to being painful) and phonophobia (noise avoidance due to being painful). They are also typically unilateral (one-sided). A mnemonic used for remembering the typical features of a migraine is POUND: Pulsatile, One-day duration (i.e., longer than the other headaches), Unilateral, Nausea, Disabling. Migraines also can present with auras preceding, which are visual changes noted before the onset of the headache. So, if the patient did have a one-sided headache, particularly in tandem with these other symptoms, and it resolved within a few days, it would likely have just been a migraine (or sinus headache, see below). However, cluster headaches (more common in males) last fifteen minutes to three hours, and tension headaches last four to six hours, and both present with different clinical pictures anyway, so a headache-like process representing these lasting for multiple days is much easier to differentiate.

However, in addition to the above, the patient presented with a sinus headache with three days duration. A sinus headache is one where there is inflammation in the sinuses of the facial bones (primarily around the nose) and can present with a headache. As such, the patient could have presented with pain and tenderness in their face (particularly their cheeks), potentially with puffiness (due to inflammation) with or without an associated headache. Alternatively, the paired frontal sinuses are just above the eyes, the ethmoid sinus lines the roof of the nose, and the sphenoid sinus is located at the top of the nasopharynx (the part of your throat behind your nose), and inflammation of these sinuses could easily present as a headache without facial signs.

So, all that said, the assumption is that this is a particularly severe headache, likely a migraine or sinus headache. Due to the admission to hospital, potentially the patient has seen a primary care physician and been referred after three days of strong headache without response to treatment (refractory headache). Alternatively, the patient has presented themselves to the emergency department directly with an extremely strong headache that hasn’t resolved in three days. However, the case then goes on to state that another three days later the patient presented to the emergency room due to worsening pain ((Sa MM, Relvas A, Leandro S. Till Death Do Us Part. Journal of Clinical Case Reports 2016;6(4):1-.)). This makes it unlikely that the original “admission” was actually an admission and was either poorly worded (misuse of terminology) or the process in that locale is different.

Examination

The next step after establishing the patients history is to perform an examination. Technically, a complete examination is recommended for all patients to ensure nothing is missed. Realistically, an overview of the whole body with then a focus on the system involved with the presenting complaint is normally done. The overview of the whole body follows a model known as the tip to toe model, starting from the fingertips, proceeding up the arms, then from the apex (top) of the skull down through the neck, trunk (chest and abdomen), legs, and finally to the toes. This thorough process is designed so that no important physical abnormality should be missed.

At each step, numerous things are examined which can give signs of issues even in distant systems. For example, in the fingers alone and just for a cardiovascular (heart) issue, signs can include clubbing (flattening of the angle of the nailbed, associated with many diseases but specific to cardiovascular is often congenital), palmar crease pallor (associated with anaemia), cyanosis (blueness, in peripheries this is often congenital), xanthomata (fat deposits, associated with hyperlipidaemia or too much fat in the blood), splinter haemorrhages (normally manual labour and hand trauma, but can be a sign for infective endocarditis), Janeway lesions, Oslers nodes, and various dysmorphic features, among others. In the eyes, xanthelasma (fat deposits around eyes) can indicate familial hypercholesterolaemia, conjunctival rim pallor (paleness of the conjunctiva, the mucosal rim around the eye, where conjunctivitis occurs) can indicate anaemia, and icterus of the sclera (yellowing of the white parts of your eyes) is an early sign of jaundice which, most commonly, is caused by liver damage but does also have cardiovascular causes such as haemolysis (breakdown of red blood cells and their products).

Further to the tip to toe method, during the examination the Medical method is generally followed (although some systems, particularly the nervous and musculoskeletal systems, use other models). This method involves progressing through four major steps: Inspection, Palpation, Percussion, Auscultation. Inspection indicates those things that can be seen without touching, palpation is feeling (for example, detecting a heartbeat, pressing on the abdomen, or pressing around a mass), percussion is placing one finger flat against the body surface and tapping on it with the other hand like a hammer in order to listen to the sound produced, and finally auscultation with the stethoscope to listen to sounds.

In this case, the history will have provided most of the information, and beyond that inspection may have shown inflammation. The accessible sinus areas were likely palpated, as would have been the lymph nodes along the base of the chin, around the ears, and down the neck (the cervical and supraclavicular chains). The lymph nodes are where infective processes drain to, and these can be enlarged during and following infection and inflammation.

Investigation

Finally, the third part of medicine is the investigation. Investigation is the stages that involve sending away for tests, and can range from taking blood samples and analysing these at the lab (very common), through to imaging (ultrasound, x-ray, CT, MRI, nuclear medicine scans, etc.), through to invasive procedures such as biopsy or exploratory surgery. In this case, blood work will have almost definitely been done, but with the unresolved progressive sinus headache with a 6 day history a CT scan (computed tomography, commonly called a CAT scan in the USA and in media) was performed. This showed a brain mass, which will have been the cause of the patients pain. “Many tests” ((Sa MM, Relvas A, Leandro S. Till Death Do Us Part. Journal of Clinical Case Reports 2016;6(4):1-.)) are then stated as having occurred, which likely involved further imaging, more extensive blood work, and almost definitely a biopsy. These all resulted in a finding of a stage IV Glioblastoma (previously known as a glioblastoma multiforme), a severe brain tumour that falls into the category of astrocytoma’s. Astrocytoma’s, as the name suggests, are derived from the astrocytes of the brain, which are cells that perform many supportive functions.

Many people will think that if a severe malignancy is possible why wasn’t a CT done previously. Investigations are costly and often time-consuming. Imagine what would happen if every single person ever who had a headache was sent for a CT scan to happen. Not only could the radiology practices not keep up with the demand, but the financial burden would be astronomical. Almost all of these scans would also display no sinister process. Finally, CT scans subject the patient to high doses of radiation which should be avoided unless it is clinically justified and would change management.

Furthermore, for almost any condition or symptom, a substantial differential list can be created. For something as simple as “I feel off” (likely meaning either malaise or lethargy) the diagnosis could range from something as simple as a subacute viral infection to anaemia through to malignancy. A blood test would likely be performed (particularly as anaemia is a consideration), likely with LFTs (liver function tests), TFTs (thyroid function tests), and electrolyte tests (testing kidney function) added, but if nothing significant showed up then a minor viral illness would be most likely. This is why a thorough history is important, backed up by a solid examination, but even then, investigations should only occur if there is a substantial likelihood of issue. In this case, the history and examination will have correlated with a sinus headache, and so that diagnosis was made. When the symptoms worsened the diagnosis time-consuming and further investigations were performed.

Conclusion

This case ((Sa MM, Relvas A, Leandro S. Till Death Do Us Part. Journal of Clinical Case Reports 2016;6(4):1-.)) has been a reasonable analysis of thinking through a case from a medical mindset, despite only being one paragraph long. Future posts in this series should tend towards the complete case analysis occurring within one post. Analyses that would go longer than a single post will instead be focused on the important aspects of the case or medical thought process.

I hope you have enjoyed following along with me thinking through this case, and I hope that it has expanded your understanding of what goes on in medicine. Feel free to subscribe to my blog (on the right for desktop, below for mobile) for future posts, and if you have any queries or comments I would love to hear from you below. Until next time, be healthy and continue learning.

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