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A Case to Challenge Medical Judgement

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A 77 year old lady is referred for headaches. She has had a long history of episodic migraine that has had cycles of being better and worse. She has now developed a daily headache as of three months ago that seems to be worsening. Her migraines were never daily (highest frequency twice a week) and used to be unilateral although sometimes they were bilateral.


This new headache is holo-cephalic and few associated symptoms. Her migraines did have photophobia most of the time and rarely nausea and vomiting.


She's had a normal MRI brain a month ago.


PMHx: Confirmed Dx of PMR two years ago. Had bilateral TA bxs at that time and they were negative and were met with complications. She had a significant scalp hematoma and hemorrhage (bx wound keep bleeding) requiring three days hospitalization (should have been an out patient procedure). She is on Coumadin for AF. She was placed on prednisone by the rheumatologist (Dr. x) for the PMR two years ago. She hated the way it made her feel and stopped it after four months and never went back to the rheumatologist (Dr. x) and doesn't like the man. Her sed rate has been running between 70-90 consistently ever since.


During the visit the patient is with her daughter. She is stubborn and her daughter supports her mothers feelings. She says that she knows the headache is just her old migraine being aggravated by stress. I mentioned that I might like to have her go back and see Dr. x for an opinion and she says no way. I tried to refer her to rheumatologist Y (in a nearby city) and he says he won't see her because she is a patient of Dr. x.


How do you proceed?

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I would ask: how can I help you? ... What are your expectations of this visit?


Depending on the answer, I might mention to them what I think the probable diagnosis is ( here mike, you need to interject whether or not you believe the PMR dx and whether or not you perceive these headaches to be reflective of that disease.. Or whether you agree with the patient's perception that the headaches are a reemergence of migraines ( I do not think this to be the case).)


If the goal of their visit is to determine what the headaches are... Then tell them what you believe they are, and make a proposed treatment plan. Which, depending on your practice style, may include steroids given , as Eric suggested, in a different form than the one she previously had been on..

And , again practice style, a referral to rheumatology for concurrent management as PMR involves the whole body, not just the head and neck.

If they balk, or are not interested in following your treatment plan if it includes steroids because of side effects and rheumatology because of whatever, then you have an ethical decision: do I continue treating folks who will not partake in those treatments Which I believe to be Essential to my diagnosis... Compromising and cutting corners in treatment modalities in accordance with the patient's wishes.

Guys in family practice do that all the time.

I think as part of your agreement to take care of them is the inherent obligation on the patient's part to at least try your treatment plans. And to recognize that if they do not want to accept those treatments, then you may not NE able to continue taking care of them.




You could continue taking care of them, trying alternative management methods.. ( Is there an alternative treatment to steroids in PMR???... Immunmodulators????).... Maybe helping her with the pain... With a video recorded and written statement signed by both patient and daughter that they understand the risks not taking the treatment of PMR, and their desire to essentially do nothing for their primary problem.


I think I would present them with a written diagnosis of what I think is the cause of her headaches, and a proposed treatment plan, and let them decide what they want to do.


Seeing you is a privilege - not, until at least obamacare takes effect- a right.


The same as treating them is a privilege for you.. Not an obligation.


The issue is clear.. How far should you allow a patient to dictate a course of therapy which may be, in the end, deleterious to their health?


I would try like crazy to steer them towards the right path, encourage and love them the best you can, but be willing to cut them lose if the push back is too great.

Just my rambling 7 am thoughts.

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So this is how it has panned out, at this point.


First of all, I will say that some patients add insight into their diagnosis through their intuition. But sometimes, as I think in this case, it is a denial. When I told the patient and her daughter on the first visit that I'm very worried about TA, they both smiled and daughter said "No, she doesn't have that. They tested her for that already."


I explained that PMR and TA often like to ride in the same car. However, they don't always leave the garage together. PMR might pick up TA way down the road . . . like two years down the road.


I was disappointed that Dr. Y refused to see her simply because she has already see Dr. X.


So I spoke to Dr. X yesterday. We both stumbled through the case trying to figure out the best course of action. So in summary, I'm starting her on Prednisone 60 MG a day for a week and seeing her back at that time. If she has had a significant improvement, then Dr. X and I agree, that we will make the dx of TA. Then I will insist that she follows back up with Dr. X because I'm not going to follow a 77 year old on high doses of steroids for a year.


I called that patient and explained the plan. She was disappointed but seemed to be willing. She was a little bit more motivated when I called yesterday because she has had some "dark spots" in her vision (never had migraine with aura) that came and went though-out the day. I told her if she didn't get the steroids on board ASAP, she might go blind.


The Rheumatologist did share a caveat. He said if you palpate the remaining branch of the TA, just above the TMJ, and you feel no pulse, then you put them on steroids for 72 hours, THEN you feel a pulse, it is another diagnostic finding for TA in someone who is post-TA biopsy.

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