Primary Care of the Family II

OSCE 13: Headache Video Transcript

Narrator: This video is designed to help prepare you for objective structured clinical examinations, or OSCEs.

You are about to participate in the office visit of a 21-year-old college student with a complaint of headache. As you watch this encounter, you will be asked to answer questions while the image on the screen freezes.

These questions will engage you in practicing the skills of focused history taking, physical examination, and clinical reasoning as you develop your preliminary differential diagnosis based on the guidelines designated in the USMLE Step II Clinical Skills Examination. You are expected to develop three diagnoses with supporting history and physical examination findings, and to list the diagnostic workup studies you would order.

You will have time to record your findings and receive feedback.

Health History

Clinician: Good morning, David. Tell me your special concerns today.

David: Well, I have a headache that started last night, and it's gotten worse. My college roommate told me I should go see the doctor today and I wasn't going to, but I realized how bad I feel.

Narrator: What preliminary diagnoses are you considering at this time? Press pause and list your answers. Resume when you are ready to receive feedback.

Answer:

Clinician: Can you tell me more about how you're feeling?

David: There's not much to tell. I've been under a lot of stress lately, because of exams. Can stress cause a headache?

Clinician: Yes, it can. Have you had a headache when under stress before?

David: No, not really.

Clinician: Then there must be something different about what's causing your pain this time. What do you think it could be?

David: I had a sinus infection last week, here [points to left eye] but I took some antibiotics that I had from the last time I had one of those. I took it and it got a little better.

Clinician: Not cured?

David: Well, I still have a runny nose, and over the past couple of days, I felt a little achy and shaky, but I've just been pushing myself because of exams. That just comes with the territory in college.

Clinician: When did the headache start?

David: Last night. A little at first, then more, then it started to throb, and I couldn't sleep well. I was just going to take the exam and then come here if it didn't get better, but I decided to come here first.

Clinician: This headache must be unusual for you.

David: Yeah, I don't get headaches very often.

Clinician: Is there anything else going on besides the headache?

David: I can't eat.

Clinician: You haven't been eating?

David: Not since the headache started. And lights hurt my eyes.

Clinician: Have you had any fever or chills?

David: I feel hot, but I don't know what the nurse found.

Clinician: Have you noticed any skin rash?

David: Well, maybe, here [points to abdomen].

Clinician: Have you had headaches before, that weren't related to stress?

David: No, not really. Sometimes if I feel one coming on when I'm really busy, I take two ibuprofen, and I'm fine.

Clinician: Do people in your family have headaches?

David: No.

Clinician: What else can you tell me about this headache?

David: There's an ache to it, an ache all over, and it's getting worse.

Clinician: How bad is it, if 10 is the worst pain, and 1 is minimal pain?

David: I'd say now it's a 9 out of 10.

Clinician: Can you point to it?

David: No, it's really all over.

Clinician: Have you vomited?

David: Well, yeah, this morning when I got up. That was bad. That's not something I usually do.

Clinician: Is there anything else? Weakness? Numbness? Tingling? Double vision?

David: No, my vision is okay—no weakness or tingling. I do feel a little sleepy, though, and it's hard to concentrate.

Clinician: How is your general health? Have you had any serious problems?

David: The sinusitis, like I said. That's all.

Clinician: Do you smoke or do drugs?

David: No, but I do drink. The last time I had a beer was a week ago.

Clinician: It sounds to me like you've been doing well until last week, when you had sinusitis. The sinusitis may have responded somewhat to the antibiotic pills you took, but not entirely. Now, you have a new kind of headache, which is getting worse and has caused you to feel achy and to vomit. Lights are starting to bother you, and you feel a little drowsy.

David: [Nods] Yes.

Clinician: Is there anything else?

David: [Shakes head] No, I think that's it.

Clinician: Let's turn to your physical exam, and then we can talk over causes and next steps. I'd like you to change into just your shorts and a gown. I'll perform a thorough examination, including looking at your skin.

Physical Examination

Narrator: With the patient's health history in mind, and after performing good hand hygiene, you are ready for the physical examination.

Clinician: Your blood pressure is 100 over 60, which is a little low. Your heart rate is 100 beats per minute, which is on the fast side. Your breathing is also a little fast, at 20 breaths per minute. Your temperature is 99.1 degrees, which is slightly above normal.

Narrator: What areas of the physical examination are important for this patient?

Press pause and list your answers. Resume when you are ready to receive feedback.

Neurological examination, including mental status, cranial nerves, motor and sensory systems, and reflexes.

Clinician: First, I would like to look at your skin carefully on the front and back.

David: Okay.

Narrator: Examine the skin on the face, and on the front and back of the neck; on the anterior chest; on the posterior chest; and around the abdomen and groin area. It is important to examine the front and back of the patient's thighs and legs.

Clinician: I agree about the spots you noticed. And I see you have a faint rash here on your abdomen.

David: It wasn't there last night.

Clinician: Now I want to examine your head and neck, especially your eyes, ears, sinuses, and the back of your throat.

Narrator: Examine the head and neck, with special attention to the fundi.

Clinician: Do you feel any tenderness here over your sinuses?

David: Yes, a little.

Clinician: Can you bend your neck forward?

David: No! Don't do that.

Clinician: That causes you pain?

David: Yes.

Clinician: Your eye movements and pupillary reactions are good. I'm going to look in the back of your eyes, which we call the fundus, for papilledema, which is swelling caused by pressure in the brain. I can see the venous pulsations, which is good and there's no evidence of pressure that can cause bulging of the optic disk. Your eardrums look good.

David: Well that's good.

Clinician: Open wide for me, say "ahhh." Your throat is a little inflamed, but I don't see any areas of pus. There are some nodes, but they feel rubbery and movable, which is okay.

Narrator: Carefully examine the nervous system, including mental status, cranial nerves, motor and sensory systems, and reflexes. Observe and assess the patient's mental status, including orientation and concentration.

Clinician: Ok, what is the date today?

David: December 13th?

Clinician: Now subtract 7 from 100.

David: 93

Clinician: Ok, and 7 from that?

David: 86

Clinician: Ok, keep going.

David: 79 – 74. Ok, I'm sorry I can't do it.

Clinician: All right. I'm going to start your neurological examination.

Narrator: Examine the 12 cranial nerves.

Clinician: I've checked your cranial nerves, which travel from your brain and supply important nerves in your face and neck for vision, hearing, speech, and they're all fine. I'm going to check the strength in some of your muscles, sensation, and reflexes. I know you don't feel well. Would you like to lie down, or stay sitting?

David: Sitting up is okay if it's not for too long.

Clinician: Okay, good.

Narrator: Test motor and sensory function and reflexes, including the plantar reflex. Perform this examination comparing the left and right sides.

Clinician: Alright, now I'm going to check the triceps. Hold your hand like a knife, alright, now push down. Very good. Other side, hold your hand like a knife and push down for me. The strength in your arm muscles is fine. Let's take a look at your knee and ankle strength.

Narrator: Test knee flexion and extension.

Clinician: Same thing, don't let me pull.

Narrator: Test plantar flexion and dorsiflexion. Test sensation to pinprick.

Clinician: Is this sharp?

David: Yes.

Clinician: Is this the same?

David: I feel something sharp on both sides.

Clinician: Does this feel sharp too?

David: Yeah.

Clinician: Is this the same?

David: It is.

Clinician: I'm going to check your reflexes now.

Narrator: Test the reflexes.

Clinician: I'm going to test the knee reflexes, and this side too.

David: My reflexes seem pretty good!

Clinician: Yeah. Now I need to check your reflex on the bottom of your foot. Let's have you lie down.

Narrator: Test the plantar (Babinski) reflex.

Clinician: Your big toes go down, which is normal.

Narrator: Test the Brudzinski sign. In a positive Brudzinski sign, as the examiner flexes the neck (passive flexion), the hips and knees flex due to lumbar or sacral nerve root irritation. Test for the Kernig sign.

Clinician: Now I'm going to flex your hip and knee, then slowly straighten out your leg. Tell me if this bothers you.

Narrator: In a positive Kernig sign, due to lumbar or sacral nerve root irritation, there is pain and increased resistance to knee extension when the hip is flexed to 90 degrees.

David: Ow! Don't stretch my leg out like that.

Diagnostic Considerations

Narrator: What are your three diagnostic considerations, in order of priority? Press pause and list your answers. Resume when you are ready to receive feedback.

Diagnosis 1: Meningitis: Meningitis is a rare but potentially fatal cause of headache, and can be missed in college students. Like subarachnoid hemorrhage, because meningitis is potentially life-threatening, it always should be considered in the differential diagnosis of headache.

This 21-year-old college student has subtle but concerning features of meningitis, which can be missed in young adults under stress who present with cold or sinus symptoms.

In meningitis, a recent sinus condition can be a parameningeal focus for subsequent meningitis. The patient presents with a first episode of increasingly severe headache. He rated his pain as 9 out of 10. He is starting to feel drowsy. A high index of suspicion is warranted.

On physical examination, the patient looks fit but fatigued, even a little sleepy. His temperature is 99.1 degrees. His blood pressure is somewhat low, at 100 over 60, and his heart rate is elevated at 100 beats per minute.

Careful inspection shows a faint petechial rash on the trunk. The patient also has nuchal rigidity, mild sinus tenderness, and limited pharyngeal inflammation, but no exudates.

On neurological examination, the patient is alert, but with a hint of early deterioration in concentration ability on the serial 7's test. Findings include meningeal irritation on the Brudzinski and Kernig tests. However, there are no other focal findings.

Mental status change, fever, neck stiffness, and nuchal rigidity are common presenting findings in meningitis. Usually, at least two of these signs are present. These signs, plus headache and rash on the trunk or extremities, are suspicious for meningococcal meningitis in a college student or military recruit living in an enclosed setting who is otherwise healthy. Symptoms usually occur 3 to 7 days after exposure from close contact with an individual with a throat infection or respiratory secretions.

Since the advent of the Haemophilus influenzae type b vaccine, the pneumococcal conjugate vaccine, and the quadrivalent meningococcal conjugate vaccine, the incidence of bacterial meningitis has declined, especially in infants and children. But cases still occur because the vaccines do not cover all serotypes.

Neisseria meningitidis accounts for 14 to 20% of meningitis cases.

Predisposing factors include recent respiratory or ear infection, otorrhea or rhinorrhea, exposure to an infected individual, immunocompromise, prior head trauma, and recent travel to sub-Saharan Africa.

Skin examination is diagnostically significant in this patient. Meningococcal bacteremia can produce a pink, red, or purple rash that can darken and enlarge into confluent bruises as infection progresses. Early diagnosis and treatment are critical to prevent rapid and fatal progression of infection.

Diagnosis 2: Migraine: Migraine can be considered in the differential diagnosis of this patient, because of the stress of exams and his headache severity, nausea, photophobia, and stiff neck. However, he lacks several signs of migraine: a preceding aura with flashing lights or scotomata, which is present in 25% of cases; unilateral location; a pulsatile quality, and pain that increases with activity.

The patient also has a fever, which is unusual in migraine. This is also his first headache, and most migraines are episodic, with occurrence fewer than 15 days a month. Migraines usually begin in late childhood or adolescence, run in families, and are three times more common in adult women than in men. Common migraine triggers include stress, lights, and alcohol ingestion.

These features distinguish migraine from other primary headaches such as tension headache, cluster headache, and trigeminal autonomic cephalalgia.

Diagnosis 3: Tension headache: Tension headache is the most prevalent form of primary headache. Usually it is less severe than headache from migraine, meningitis, or subarachnoid hemorrhage (which some patients describe as "the worst headache of my life").

Diagnosis of tension headache is based on excluding the features of migraine or headache from an underlying systemic cause.

Tension headache is typically bilateral, non-throbbing, and mild to moderate in severity. Patients often describe tension headache as "dull pressure." Stress and poor sleep are common triggers, and there may be scalp tenderness, which is relieved by massage. The neurologic examination is intact.

Diagnostic Workup

List the next three steps in your diagnostic workup.

Press pause and list your answers. Resume when you are ready to receive feedback.

Diagnostic Study 1: Lumbar puncture: Lumbar puncture should be performed immediately, unless the patient has focal neurologic findings, a possible central nervous system mass, or other contraindications. Lumbar puncture is needed to distinguish bacterial from viral meningitis, which cannot be done based on clinical findings. It also provides critical cerebrospinal fluid for gram stain and culture to identify the causative organism. Treatment should be initiated immediately after lumbar puncture is performed.

Contraindications to emergency lumbar puncture include immunocompromise, known central nervous system disease, new-onset seizures, papilledema, decreased level of consciousness, and risk of impending brain herniation. These contraindications raise the risk of elevated intracranial pressure.

Such patients should have immediate blood cultures and antimicrobial treatment followed by a head computed tomography, or CT scan, then proceed to lumbar puncture if there is no evidence of elevated intracranial pressure on the CT scan. Although parameters are wide, common cerebrospinal fluid findings include elevated opening pressure on lumbar puncture; elevated white blood cell count (1000 to 5000/microL) with greater than 80% neutrophils; low glucose level (less than 40 mg/dL) or cerebrospinal fluid-to-serum glucose ratio greater than 0.4); and elevated protein level (greater than 200 mg/dL).

Diagnostic Study 2: Blood cultures: Two sets of blood cultures should be obtained immediately in all patients with suspected meningitis to establish the diagnosis and causative organism and its sensitivities to antibiotics.

A complete blood count can be considered but may not reveal an elevated white blood cell or neutrophil count. Use of latex agglutination tests is no longer recommended. Polymerase chain reaction, or PCR testing, is sensitive and specific, but its use remains under study.

Diagnostic Study 3: Head CT scan: In patients with suspected meningitis but contraindications to immediate lumbar puncture, after initiating blood cultures and antimicrobial therapy, a head CT scan is indicated to evaluate possible elevated intracranial pressure or mass lesions.

Head CT scan is not routinely indicated in a patient with first-onset migraine or tension headache. Like MRI, it has low diagnostic yield in patients with chronic headache and those who lack the "red flag" headache warning signs.

Make sure you are familiar with these important signs that warn of headaches needing prompt investigation:

Summary

In summary, this 21-year-old college student with pending winter exams has a 12-hour history of increasingly severe global headache, now 9 out of 10 in severity. He had sinus congestion the previous week but has been healthy otherwise, with no history of significant headaches.

The patient now feels drowsy and reports photophobia, nausea, neck stiffness, and "spots on his abdomen." The patient has had no motor or sensory changes. He does not smoke or use illicit drugs, and his last drink of alcohol was a week ago.

Physical Examination Findings

On physical examination, he is fit and oriented but drowsy. His temperature is 99.1 degrees, and his blood pressure is low at 100 over 60, with a slightly elevated heart rate of 100 beats per minute. The patient has a pink petechial rash on his abdomen and mild sinus tenderness and pharyngeal inflammation without exudates. He has nuchal rigidity and some loss of concentration, but no focal neurologic findings. He has an intact plantar reflex, and his Brudzinski and Kernig tests are positive.

Diagnoses

Diagnoses include meningitis, migraine, and tension headache.

Diagnostic Studies

Possible diagnostic studies include lumbar puncture, blood cultures, and a head CT scan.

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