CMS Family Medicine Form: Cluster Headache

CMS Family Medicine Form
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Cluster headache
 Clinical presentation Severe unilateral orbital, supraorbital, or temporal pain. Unilateral autonomic
symptoms are ipsilateral to the pain and may include ptosis, miosis, lacrimation, conjunctival
injection, rhinorrhea, and nasal congestion.

 Tx For patients with acute cluster headache, initial treatment with either triptans or oxygen. Oxygen
should be tried first if available since it is without side effects.

 DDx Trigeminal neuralgia - primary stabbing headache is characterized by transient, sharp jabbing
pains that occur within a small, localized area of the scalp, exclusively or predominantly at variable
locations within the first division of the trigeminal nerve. The stabs last from 1 to 10 seconds and
occur at irregular intervals from one to many times each day. No associated cranial autonomic
symptoms.
Acute suppurative thyroiditis
 Caused By bacterial infection, pyriform sinus fistulas are present in up to 70 percent of children
 Lab Thyroid function tests are usually normal
 Tx Antibiotics, covering S. aureus, S. pyogenes, gram negative, bacilli - give clindamycine
Chronic lymphocytic thyroiditis (Hashimoto disease)
 Definition Clinically by gradual thyroid failure, with or without goiter formation, due primarily to
autoimmune-mediated destruction
 Lab High serum concentrations of antibodies to thyroid peroxidase (TPO) and thyroglobulin (Tg)
 Clinical presentation Gradual loss of thyroid function.
Drug induced thyroiditis
 Interferon alfa, interleukin-2, amiodarone, lithium, a tyrosine kinase inhibitor
Euthyroid-sick syndrome
 Seen in hospitalized patients. Low serum concentrations of both thyroxine (T4) and triiodothyronine
(T3), and their serum thyroid-stimulating hormone (TSH) concentration also may be low.
Exogenous hyperthyroidism
 Exogenous hyperthyroidism have low serum TSH concentrations. Serum T4 and/or T3 may be
elevated, a low or undetectable 24-hour radioiodine uptake differentiate exogenous hyperthyroidism
from other causes of hyperthyroidism.
Subacute thyroiditis
 Neck pain, a tender diffuse goiter, and a predictable course of thyroid function evolution.
Hyperthyroidism is typically the presentation followed by euthyroidism, hypothyroidism, and
ultimately restoration of normal thyroid function

 Tx Pain relief, anti-inflammatory therapy with either aspirin, NSAIDs - if there is no improvement in
pain in two or three days, the NSAID should be discontinued and prednisone initiated.
Painful diabetic neuropathy,

 Tx Amitriptyline, venlafaxine, or duloxetine or pregabalin. Among these options, we prefer to start
with amitriptyline, particularly in younger healthier patients . For patients who are unable to tolerate
any of these drugs, alternative treatments include capsaicin cream, lidocaine patch, alpha-lipoic
acid, isosorbide dinitrate topical spray, and transcutaneous electrical nerve stimulation.
Diffuse (distal) esophageal spasm (DES)
 Clinical presentation Usually symptomatic and present with dysphagia for solids and liquids,
retrosternal chest pain, heartburn, or regurgitation

 Dx Upper endoscopy and biopsy to rule out other structural esophageal disorders. If noncardiac
chest pain or GERD symptoms (heartburn or regurgitation) that are refractory to twice daily proton
pump inhibitor (PPI) therapy, we perform esophageal pH and impedance testing. If the above
evaluation is negative, we then proceed to esophageal manometry testing to establish the diagnosis
of a specific esophageal motility disorder
Hyponatermia in CHF
 Mechanism When cardiac output and systemic blood pressure are reduced, "hypovolemic"
hormones, such as renin, antidiuretic hormone (ADH), and norepinephrine, respond. Although
edematous patients with heart failure have increased plasma and extracellular fluid volumes, the
body perceives volume depletion (reduced effective arterial blood volume) since the low cardiac
output decreases the pressure perfusing the baroreceptors in the carotid sinus and renal afferent
arteriol.
Esophageal manometry
 Should be considered in patients with symptoms of GERD and normal upper endoscopy, especially
if there is any associated dysphagia, even though esophageal manometry is of minimal use in the
diagnosis of GERD. However, manometry is useful in identifying alternative diagnoses such as
achalasia, the symptoms of which sometimes closely mimic those of GERD.
Testing for H. pylori

 Indications Low grade gastric MALT lymphoma, active peptic ulcer disease or past history of peptic
ulcer if cure of H. pylori infection has not been documented.

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injection, rhinorrhea, and nasal congestion.

should be tried first if available since it is without side effects.

Acute suppurative thyroiditis

 Lab Thyroid function tests are usually normal

 Tx Antibiotics, covering S. aureus, S. pyogenes, gram negative, bacilli - give clindamycine

Chronic lymphocytic thyroiditis (Hashimoto disease)

 Clinical presentation Gradual loss of thyroid function.

Drug induced thyroiditis

 Interferon alfa, interleukin-2, amiodarone, lithium, a tyrosine kinase inhibitor

elevated, a low or undetectable 24-hour radioiodine uptake differentiate exogenous hyperthyroidism

from other causes of hyperthyroidism.

Hyperthyroidism is typically the presentation followed by euthyroidism, hypothyroidism, and

ultimately restoration of normal thyroid function

Painful diabetic neuropathy,

Diffuse (distal) esophageal spasm (DES)

retrosternal chest pain, heartburn, or regurgitation

of a specific esophageal motility disorder

diagnosis of GERD. However, manometry is useful in identifying alternative diagnoses such as

achalasia, the symptoms of which sometimes closely mimic those of GERD.

Testing for H. pylori

ulcer if cure of H. pylori infection has not been documented.

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