One of my co-workers told me that she wants to see more case studies.
A 59-year-old female presents to the emergency department with a chief complaint of “head pain that comes and goes.”
She describes the pain as a dull ache in her occiput that’s been striking without warning a couple of times per day for the past ten days. Over the last three days she’s noted that it has also been radiating into her neck and upper back/shoulders.
Onset – 10 days prior
Provocation/Palliation – None that she can identify
Quality – Dull ache that gradually worsens over the first few minutes
Radiation – Sometimes to her neck and upper back/shoulders
Severity – Around 9 out of 10 at its worst
Timing – Intermittent, each episode lasting ~10â€“15 minutes
Signs/Symptoms – A well-appearing 59yo F in no acute distress; symptoms as described above. She denies any associated nausea/vomiting/shortness-of-breath/lightheadedness/palpitations/syncope, but has occasionally experienced blurred-vision.
Allergies – No known drug allergies
Medications – Metformin, sitagliptin, insulin glargine, lisinopril
Past Medical History – Type II diabetes mellitus, hypertension, occasional migraines, appendectomy (40 years prior)
Last Oral Intake – Dinner three hours prior to arrival
Events Preceding Presentation – She experienced another spell at dinner and it self-resolved, but then a few hours later it came back and disappeared again. Realizing the episodes were becoming more frequent, she decided to get checked-out and drove to the ED. While she is signing in at triage she mentions that the pain is starting to come back.
Temperature – 36.9 C (98.4 F)
Heart Rate – 80 bpm
Blood Pressure – 142/88 mmHg (NIBP)
Respiratory Rate – 15 /min
SpO2 – 97% (room air)
Because of her vague symptoms and pain that involves her back/shoulders, a 12-lead ECG is performed soon after arrival.
What do you see?
What are your next steps in workup/management?
***The conclusion to the case is now posted!***