Secondary headache - differential diagnosis & examination

General examination in Stroke

Chest pain of cardiovascular origin

Pathophysiology of clinical manifestations in diabetic ketoacidosis

History taking in a patient with generalized lymphadenopathy

What are the important questions that a patient with generalized lymphadenopathy has to be asked?

What is the duration of enlargement?

What are the associated symptoms?

Does the patient have easy fatigability, bleeding tendencies?

Is there any history of joint pain, skin rash?

Are there any systemic symptoms – fever, weight loss, appetite loss

Is the patient on any medications?

Does the patient have history of high risk behavior?

2. Pain in the gluteal region. Discussion

A middle aged male presented with complaints of pain in the right gluteal region. The pain started spontaneously and hampered him from walking. The pain was worse with movement especially in getting up from sitting and climbing stairs. It was relieved temporarily with the use of NSAIDs. There was no associated back pain, no pain on the anterior or medial aspect of the thigh or below the knee. There was no history of numbness or paresthesias. On examination pain was reproduced particularly during flexion, adduction and internal rotation of the hip. There was no local tenderness and no obvious lesions on the skin.

What is the possible cause?

A principle that I follow in evaluating pain is to first think of the possible structures that could be the origin of the patient’s pain. Pain in the gluteal region may arise from the skin, subcutaneous tissue, muscles in the region, joints, bone, nerve or the spinal roots.

An infection in the cutaneous or subcutaneous plane: Furuncle, Abscess, Bursitis

Muscle: Myofascial strain, Myositis

Joint: Sacroiliitis, sacroiliac joint dysfunction

Bone: Osteomyelitis

Nerve: Sciatic nerve compression

Roots: Lumbar Radiculopathy secondary to root compression

How to evaluate the patient?

Local examination: Inspection & Palpation: Check for tenderness, muscle tightness

Move: Range of motion

Stress tests for the sacroiliac joint

Tests for piriformis syndrome

Neurological examination to check for radiculopathy & sciatic nerve dysfunction

Imaging to look for structural pathology

Special tests: SPECT/Magnetic resonance neurography

1. A patient with diabetes Discussion

A 65 year patient presents at an outpatient clinic for evaluation. She is a diabetic since 20 years and is currently on Insulin (isophane insulin 6 U at night & regular insulin 24-30-22 U before food). She was previously on oral hypoglycemic agents but has been on insulin since 6 years.

What are the possible reasons why OHAs would have been discontinued?

The high dose of insulin suggests that this patient probably had uncontrolled sugars. If a patient’s sugars are not controlled with lifestyle modification and metformin, initiation of insulin is an option  in Type 2 Diabetes particularly if Glyco Hb > 8.5%.

In addition if a patient has developed contraindications to OHAs like renal or liver dysfunction this would again be reasons for starting the patient on Insulin.

In situations of poorly controlled diabetes, while the optimal strategy is uncertain, a basal bolus regimen seems the best possible option.

She complains of imbalance while walking. What are the additional signs that you want to look for?

Examination findings to focus on in view of imbalance (cause maybe predominantly sensory, cerebellar or vestibular)

Motor system: Power tone and reflexes to look for evidence of stroke or extrapyramidal dysfunction

Sensory system: predominantly posterior column sensations, rhomberg’s sign

Cerebellar signs

Visual abnormalities

Vestibular dysfunction: Nystagmus, Vestibuloocular reflex