Hot Seat #66: 5yo M with headache and blurry vision
Posted on: December 3, 2015, by : Evan Sherman
Evan Sherman MD, Children’s National Health System
Eiman Abdulrahman MD, Children’s National Health System
The Case
5yo M presents with HA x3d. He is triaged to the “subacute” area of the ED. He is precocious and articulate for his age, however, a description of the headache is difficult to obtain due to his developmental level. The pain is “all over” his head. When asked to point to where it hurts, he places an open palm on top of his head. He has never complained of a headache before. He doesn’t think the pain has gotten any better or worse over the past 3 days. He isn’t sure if it is worse in the morning or at night. Mom brought him in today because he woke her up last night at around 3AM to ask for pain medicine. She gave him ibuprofen at that time and he went back to sleep.
Patient also endorses blurry vision. He is prescribed glasses but does not wear them often. When asked if he normally has blurry vision, he states that he does, but that this blurry vision is “different.” He doesn’t have his glasses with him. The only other symptom he has is an intermittent cough, which “he always has,” per mom.
ROS: He denies any other symptoms at all, including F/N/V/D, photo/phonophobia, rhinorrhea, SOB, abd pain, rash. Mom denies recent trauma, sick contacts or recent travel.
No significant past medical, family, or social history
Physical Exam: Vital Signs: T 36.8 HR 80 RR 14 BP 94/58 S 100% RA
He is smiling, conversant, and generally well-appearing. The only positive finding on exam is slight periumbilical tenderness. A full neuro exam is normal, including cranial nerves, motor, sensory, DTRs, coordination, and gait. Unable to visualize pt’s fundi on ophthalmic exam.
The patient was given motrin in triage, and his pain is now gone.
Questions for you:
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No comments, yet….oh that’s so unfortunate, but wow an easy time for me to just lay out my thoughts as I read the case since no one else has done so, and put myself up for chopping block as to why my reasoning may be so off….
Anyhow…starting out, it’s a hot seat case – could be something interesting, unique, etc…or not (as a number of the recent ones have doled out).
So, as I read through, my thoughts:
3 days HA – not too bad.
woke him up from sleep – uh oh, that’s not good, need to image
motrin and fell back asleep – maybe no imaging, let’s read on
blurry vision – glasses yes….but this is a difficult to assess concern, maybe something maybe nothing. anything from the eyes to occiput could be involved, as blurry vision in this age (and probably most ages truly) could really mean any sight disturbance. But that is a long tract to follow…let’s see if anything else suggests something/confirms something intracranial (optic nerve, chiasm, and the rest of the path)
moving on, cough “always has” – to go to the weird, is this a child with allergic rhinitis that has now developed a Pott’s Puffy tumor – not really developed it, but has that as the cause of his headache – something to think about (and remember to palpate his forehead)
So far, a differential all over the place….where I haven’t really mentioned common things including worsening vision, trauma/injury leading to a bruise or so…
Exam – unexciting, except that a Snellen type vision test was absent. abd tenderness, eh – have to see how that fits and time of day – could just be hungry, need to pee or something like that.
Clincher – motrin relieved pain…now motrin is not quite a godsend, but it sure helps in a lot of ways. While motrin may make muscular pain go away, it’s unlikely to eliminate pain from appendicitis, fracture, head bleed, to name a few.
Personally, I’m hard-pressed to subject a pain-free, symptom and sign free child to head imaging and radiation to worst of all find an incidentaloma that is not related to the concerns at hand. However, that said, this is all about a conversation engaging as many people as necessary to do the right thing: Parents, patient, PMD as needed. On the flip side, I’m not a strongly principled person on this and will bend if the parent absolutely refuses to accept that a CT Head is required before they can leave. But even there “absolutely” is a relative term depending on how the conversation goes.
And, finally, the fun element out there is where does the resident’s H&P and rapport, and decision-making fit into the whole piece….That’s another whole ball of wax….
Let’s see what develops.
Thanks Pavan for your comments…
Here is how I worked through the case:
5yo M presents with persistent HA x 3 days that has awakened him from sleep, associated with blurry vision that is “different” from his usual blurry vision when he doesn’t wear his glasses. His mental status and neurologic exams are normal, although his fundi cannot be visualized.
The most common causes of headache in well children include tension-type and migraine headaches, but I am always cautious in the very young child with headache. Looking for emotional stress and fatigue is important in evaluating for tension-type headace.Migraine headaches may be more likely in cases where there is a typical aura and strong family history, although I consider this a diagnosis of exclusion and don’t give this diagnosis on first presentation to the ED
.
Red flags for me in this case include:
1) the young age of the child,
2)headache of prolonged duration which has awakened him from sleep
3) concomittant blurry vision that is hard to evaluate.
My differential diagnosis for his headache includes:
–Sinusitis intermittent coughing may be secondary to postnasal drip
–Ophthalmalogic disorder– patient wears glasses so can have eye strain or acute glaucoma
–Intracranial mass—woke him up from sleep, blurred vision
–AVM- woke him up from sleep but given his well appearance and non focal exam a bleed is unlikely.
Other causes of headache(i.e., tension/migraine) can be considered after serious causes have been ruled out.
Looking back at his presentation, this patient is well-appearing with a nonfocal exam (but unknown fundoscopic exam). My diagnostic priorities include 1) neuroimaging (preferably MRI, due to better sensitivity and lack of radiation) and 2) formal ophthalmologic evaluation. If close PCP follow-up can be ensured, these evaluations may potentially be persuded on an urgent basis as an outpatient. However, if timely follow-up cannot be arranged, this patient may warrant admission and/or extended ED evaluation to pursue this evaluation.