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Solve This Case ... Or Else
Ali Tabatabaey -- A few days ago, one of my best friends called and approached me with a quiz. He was my intern in a couple of rotations last year, and today he is serving his military service as the doctor of the base.
Here it goes: One morning, your General comes to the clinic complaining of a sever sore throat which has been bothering him for a couple of days. He is a 45-year-old military general with a well-built body who is keen on working out in the gym and eating fatty stews. His chief complaint on arrival is a sore throat that started yesterday morning with his migraine headache but failed to cease with the headache last night. He did not eat any breakfast yesterday morning, and on the same day had to attend a friend's funeral.
Nausea and a single episode of vomiting accompanied the headache and the sore throat without improvement. These symptoms usually exist alongside his migraine headaches. The patient has been using herbal antacids without any response.
On physical examination, BP is 120/80 and the PR 65. The throat examination is difficult due to the accompanying nausea, but everything seems normal without any erythema. The patient holds his throat every now and then, just above the Lewis angle, in order to relieve the pain, but without much success. He is more agitated and irritable than his usual behavior.
What would you do? You've only been practicing as a physician for the past five months and this guy is a very important person. Keep in mind that a misdiagnosis could mean anything from a written disapproval of your practice to permanent exile to a distant base (well, maybe not that much). Still, if you make the correct diagnosis you will have improved your situation in the base considerably.
I'll be reading your comments and will answer any questions. I made the wrong management mistake on this patient and I want to see if I'm alone, or did I make a common yet grave mistake.
April 17, 2006 | Permalink
Comments
Ali: there are many questions that come to my mind...
Like for example: is he alergic to something (drugs, food?), or if he had fever.
Another possibility that comes to my mind is: was his neurologic exam normal?, any cervical problem? (what about a cervical X-ray?)
I must admit that is a hard situation for any "new" in the area. I´m from Argentina. I got my degree on march 2005, and i´ve been working in a public hospital since June 2005. I´ve seen many patients since then, but i find hard to face this case.
I´ll wait for some extra data hoping that it will clear my vision, if not, then, you are not alone, i´ll join you in ignorance...
PS: Forgive my english, it´s been a long time since i last wrote in this language. Hope your friend had a happy ending
Posted by: Trinidad | Apr 17, 2006 8:39:02 PM
Expectant management... Did he have symptoms of upper resp tract infection except for the throat? It puzzles me though that his nausea has not subsided, maybe he should quit the herbals. A quick neurological exam is warranted, but I believe that most would go with my first suggestion.
Posted by: Anders | Apr 18, 2006 5:07:05 AM
well, with the history you've given, you have to consider a neck abscess (and check with lateral neck x-ray) or the possibility of retained food, or even an esophageal tear if the vomiting was particularly strenuous...
Of course the list goes on and on - Ludwig's angina, dental prob., strep, esophagitis (unlikely in older patients but it does happen) etc etc etc....
Posted by: juliamd | Apr 18, 2006 11:23:52 AM
dear Ali , for solving this case some additional information of this patient history & exams is needed:
1) what was the body temprature on exam and is there any report of fever by patient?
2) is there any symptom of dysphagia? or drooling?
3) is there any signs of respiratory distress? (you mentioned that he was agitated)
4) is there any sign or symptom of Upper respiratory infection?
4) is there any change in patient speech ( for ex "Hot potato" pattern) or in his vocal tone?
5) what is his drug history? specialy his drug that used on the begining of migraine attack?
6) did he make stridor in breathing?
7) did he have special position on his neck?(i e, ext in atlanto-oxypital and flex in lower part of neck)
8) is There any history of alergy?
9) what was his last food before start of his sore throat?
answering to this questions are the first and most important step for diagnosis.
i m waiting for your reply.
Posted by: idin | Apr 18, 2006 3:10:48 PM
Could it be a Mallory Weiss tear? Maybe even with a hiatal hernia? Barrett's esophagitis? Was his vomit clear or bloody? How often does he have migraines?
What kind of herbal medicine was he taking? What was he taking for his migraine? NSAIDS? Did he have a fever? Allergies?
I would do a barium swallow test if the pain persists. In rare cases, a GI cancer might be present. Or, it may be just viral.
Posted by: CH | Apr 18, 2006 3:50:47 PM
Or, perhaps, it could be an atypical presentation of acute coronary syndrome or MI.
Posted by: CH | Apr 18, 2006 3:54:51 PM
Trinidad, your English is wonderful. I wish I could say the same about my Spanish.
Ali, my gut response as a nurse was an MI. My next thing was something neuro because of the behavior change (more irritable, agitated).
A type of meningitis?
This is why you all are the docs and I'm the nurse...
Posted by: Kim | Apr 18, 2006 11:29:55 PM
Order a complete rectal exam if all else fails! At least you will get to the General's butt before he kicks yours! Sounds like an MI or maybe a mini stroke. AS for the throat... With the little info given try strep or, given the placement of his hand for soothing pain, what about an impacted gland or lymph inflamation?
Posted by: Chef Mo | Apr 18, 2006 11:44:08 PM
definitely agree with idin et al. that more history is needed-- esp considering it's a throat issue, start with ABC's--first and foremost is the general having significant difficulty maintaining airway? anaphylaxis? what was he doing when the headache started/sore throat started? has anything like this ever happened to him before? he mentions herbal antacids-- does he take them for reflux?ulcers?attempt at an antiemetic? how long has he been taking them? any other symptoms going along with this that he can think of-- dizziness?fever?chills?sweats?cough?neck pain?exposures?
Posted by: | Apr 19, 2006 4:42:37 AM
Sorry for my English !
fewer? Did it start after meal?what meal?
What was he taking for his migraine? NSAIDS? Allergies?
X-ray of lungs and esophagus with barrium?
lungs exam?ECG finding?
Neurological findins?
i am waiting for your reply
Posted by: Oskar | Apr 19, 2006 9:37:15 AM
Is the pain of pulsating quality? I'm thinking of carotid artery intima tear (sorry my english...) and maybe a clot in the brain. Carotid echo ?
Posted by: Liina | Apr 19, 2006 9:49:30 AM
Could it be onset of laryngeal CAncer?
Does the general smoke?
Posted by: Fazia Mir | Apr 19, 2006 10:12:25 AM
???? Glossopharyngeal neuralgia
Posted by: damodaram | Apr 19, 2006 11:09:08 AM
I’d be interested to know if this General has done any recent traveling, and if so where? I’d also like more information regarding the beef stew he’s so fond of.
A brief review of the initial information:
-severe sore throat for two days
-migraine headache
-nausea
-single episode of vomiting
-stress (friends funeral)
-taking herbal antacids
-VS BP: 120/80 HR: 65
-holding throat above the Lewis angle
-agitated and irritable
I’d like to know what his baseline VS are, the name of the herbal antacid, what his emesis looked like. Are his bowel sounds normal and is he having normal bowel movements? Is his skin warm and dry, or pale and clammy? What’s his skin turgor like? Is he afebrile? Are his lungs clear? Is his RR normal, what is his 02 saturation? Has he ever had a similar experience?
I’d want to do a rapid strep test, labs - electrolytes, CBC w/diff. If he’s traveled to an area w/known health issues, I’d want to do test related to those. If I feel he may have picked up something from the meat in the stew, then I’d wish to do test to rule that out. Depending on how his lungs sounded, perhaps a chest film.
Basically, I would want to do a complete history and physical, including a neuro exam on this patient. At this juncture there are too many unanswered questions to make a diagnosis.
Please keep us posted as you find out more information and let us know what this General eventually was diagnosed with.
Posted by: TNZKA | Apr 19, 2006 11:17:49 AM
I am interested in the BP in both arms and what his EKG looks like. Is there a history of fever, leukocytosis? Any prior hx of HBP? Any recent trauma?
The logical initial thought is some viral illness or bacterial pharyngitis such as group A strep, however in this patient, vascular issues need to be considered. Could the neck pain and nausea be due to inferior ischemia? Could he be disecting a thoracic aneurysm?
Finally, thyroiditis with thryoid storm brewing needs to be considered however this is unlikely with his current BP and pulse. Is his thyroid gland tender?
Any new murmers? Any crepitence in neck or sub-Q air?
A chest X-ray could be helpful looking for mediastinal empnysema or widening.
My WAG is that he was suffering an aortic disection which went into his RCA causing inferior ischemia and the nausea.
Posted by: Bill Blanchet | Apr 19, 2006 6:36:44 PM
i would highly suspect of him having meningitis. just to be on the safe side it would be suggestable if neuro examination wqas done, like to test for kernig's sign or brudzinski's sign.
what happened to him finally???how did u manage that guy??
coming from me..a 4th year medical student i am most likely wrong
Posted by: balkis | Apr 19, 2006 11:09:31 PM
Strangely, he had no fever alongside the sore throat. He does not give any known history of allergies. The initial respiratory exam was unrevealing and no dyspnea, stridor or strange posture was evident. The throat looked normal too and surprisingly it seemed that swallowing does not aggravate the pain. That morning he had eaten a stew (KALLE PACHE) for breakfast.
Meningitis was a great guess Kim and Balkis, especially in a country where it is very prevalent in military bases. But he has been vaccinated and no rigidity was seen on examination and kernig's or brudzinski's signs were not positive.
The general doesn’t like to complain of pain so the simple fact that he had come to the doctor means that this is his first time experiencing it. He usually has a migraine attack when he doesn’t eat breakfast and is hungry for a long period of time (like that morning). But other precipitating factors might cause the attack too.
The patient also likes to keep away from strong drugs. So he usually just tries to control his headaches with acetaminophen and Indral. I don’t know the name of the herbal medicine in English (AVISHAN) but I’ll look it up.
I’ll give you a couple of more days to think about it. See you then!
Posted by: Ali Tabatabaey | Apr 20, 2006 1:35:33 AM
A mere 3rd year medical student opinion. Would it be something to do with raised intracranial pressure e.g. space occupying lesion? A parasitic infestation of the brain with some abscess? Did an CT scan/ MRI was done?
Posted by: Sam | Apr 20, 2006 6:29:41 AM
Avishan is Sweet Marjoram, a common herb used in cooking. It leans toward the spicy and pungent.
Posted by: CH | Apr 20, 2006 9:36:39 AM
But what about the pulsating quality? I'm still betting on the carotid artery dissecation :)
Or maybe he is just having a heartburn...
Posted by: Liina | Apr 20, 2006 9:48:53 AM
Maybe I'd had suspected meningitis and I'd had examinated the fundus after be sure that there aren't a cervical bruit or antecedents of GER. But why not an aneurysm that's going to a rupture? What happened?
Posted by: Enrique | Apr 21, 2006 12:01:01 AM
"...it seemed that swallowing does not aggravate the pain" but he holds above the Lewis angle to alleviate the pain. So if we assume that pain etiology is inflammatory, not neuropathic then it does not stem from pharyngeal str (adenoids etc.)but str that are more superficial( maybe he's trying to restrict movement to alleviate his pain).By saying sore throat he's probably refering to a disseminated pain so that keeps me somewheat away from aneurysms or abcesses.
I would go for thyroiditis , it may also have precipitated the migraine attack (first pain, a little later attack occured, right?)
Must see CBC(with differential),T4,TSH
and CT scan of head&neck (he's your general, cost effectiveness is not an issue:))
P.S:good strong stomach he must have, kelle pacha for breakfast?!
Posted by: zeynep | Apr 21, 2006 5:14:04 AM
it seems most likely stuck food particle in the pyriform fossa .............. or may be a parapharengeal diverticula
Posted by: ravi | Apr 21, 2006 9:56:43 AM
what kind of headache the patient has? (every day, once a week, strong or not, etc.) - it could be the sign of intoxication (alongside the absense of appetite), probably, it coukd the result of abscess(alredy opened to oesophagus), for example, paraesophageal, besides that, it could be the diverticulitis, contained the KALLE PASHE (with some parasites..)))Any fever?
what's about the CT results of the cervix region?
Posted by: Julia | Apr 22, 2006 2:55:12 AM
He has cried and cried because of his friend's death, the crying brought on the headache, the constant sinus drainage has irritated his throat because real Generals don't cry, and the mucous has caused nausea in his empty stomach. He needs to eat dry toast and see the base psych.
Posted by: JE Manchester | Apr 22, 2006 8:08:23 AM
