Okay, last case.
So I’ve got an older patient here.
I’ve got a 75-year-old woman, she has a 1-day history of headache.
好吧 这是我的偏头痛病症之一 她解释到
“Well, It’s just one of my migraines,” She explains.
Sounds pretty benign, let’s get a little bit more.
So she has a long history of unilateral migraine headaches
which previously resolved with
just a high-dose nonsteroidal anti-inflammatory drugs.
However, the character of this pain is different.
It’s very concentrated over her temple specifically,
and it’s actually tender to palpation there.
So, just with that limited history alone,
what’s the next best step in the management for this patient?
Again, you could pause and think about this for a second.
所以 选项A 仅仅更换她正在使用的非甾体抗炎药
So is it A just change the type of NSAIDs she is taking,
maybe that will make a difference.
或是表明她的想法是对的 可能只是发作性的偏头痛 安抚她的情绪
Just reassurance she’s right, probably just a recurrent migraine,
and just continue with that expected management
that’s been working for a while.
You initiate maybe a new drug, like a triptan, 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 that
indeed not every case of acute management,
just needs reassurance and it will probably resolve with time.
Because this is unusual.
New headaches and different types of headaches
always should raise attention for potential red flags.
In this case, you’re seeing unilateral temporal based pain
in a 75-year-old woman, with the area actually tender to palpation.
All of that is very, very concerning for the diagnosis of
temporal arteritis, very good.
And 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.
Therefore, immediate laboratory evaluation for simple things
like a sed rate and a CBC, for the potential for temporal arteritis.
然后 除非你开出皮质类固醇药物的处方 她不能离开
And she should not leave your clinic without a prescription for corticosteroids,
because the application of corticosteriods
can dramatically reduce that risk of complications.
So she’ll need close follow-up and an initiation of treatment right away.
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 expected management reassurance.
But certainly I think, for USMLE exam and the way I think about patient care,
the answer many times, it’s not every answer.
So the trick for you is to watch for high-risk conditions.
Now what do those conditions include?
I think headache is a high-risk condition, so always pay attention to it.
胸痛 但通常都是良性的 也是高风险因素
A chest pain, but it’s usually benign, still a high-risk conditions.
New neurological symptoms, 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 a cue.
You know, think about stroke,
you think about masses or other severe CNS disorders.
Or, and these are often found incidentally,
new lesions or masses in organs such as the skin or the breast.
I’ve got this mole,
and yeah it seems to be growing and changing,
then it bleeds and falls off, then it comes back again.
You know, the first thing I’m worried about is cancer.
Now that’s…is it going to be cancer? unlikely.
But the first thing I’m going to worry about is cancer.
And anytime somebody comes in with it.
我摸到了一个 你知道的 那种乳房包块 特别是当她们年龄超过50岁
I feel a new, you know, mass of 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.
These are the high-risk conditions. Just to name a few
but some of the more common ones that we see.
Those should, you know, alert you to the fact
that you might need to really go and perform a more thorough workup here.
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.
So hopefully you found these cases are beneficial.
Now we’ll move into the acute care module,
and you can see how this plays out with some real cases.
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