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Elderly woman with multiple symptoms including headache

Dr Steve Brown discusses another presentation

Dr Steve Brown discusses another presentation

Case History

You are looking forward to the end of a busy surgery when you see an extra has been squeezed in. Joan, 72, is complaining of a headache and irritation of the scalp and has had some floaters. She is not a regular patient, is normally in good health and last came to see you two years ago.

What does the history uncover?

She describes neck pain radiating up to the scalp, which I thought was nerve root irritation from the neck. The floaters last occurred 36 hours ago and now she reports normal vision. The headache is frontal and is worse when she bends forwards.

What are the examination findings?

She has a good range of movement of the neck. There is tenderness over the frontal sinuses and the temporomandibular joints. The temporal arteries are non tender and pulsatile and the scalp looks normal on inspection.

How do I manage the case?

I feel Joan is suffering from inflammation of the temporaomandibular joints plus sinus congestion. I advise regular steam inhalation and ibuprofen. In view of the floaters I advise her to attend her optician.

Then, five days later, she attends A&E with worsening visual disturbance in one eye and is diagnosed with temporal arteritis. She is treated with steroids and on review one week later her vision has nearly returned to normal.

How do the typical symptoms relate to Joan?

It seems her symptoms were those of early temporal arteritis. The scalp tenderness was not related to her neck, the headache was not sinus congestion, the temporomandibular tenderness was likely to be jaw (masseter) muscle involvement, and the floaters were suggestive of early involvement of the retinal artery. The fact that the arteries were not tender to palpation is again consistent with early symptoms.

Could the diagnosis have been made earlier?

Looking back it is easy to see that Joan had multiple symptoms, and that I should have been thinking about a single systemic disease as the cause. It is not that likely for a patient who is an infrequent consulter to suddenly present with sinus congestion, headache, scalp symptoms and visual disturbance. There are, however, plenty of anxious or hypochondriacal patients who could present in this way with a long list of symptoms. I was also at the end of a busy surgery and was mildly irritated that an extra patient had been squeezed in. Joan presented with early symptoms of temporal arteritis, making the diagnosis more difficult. If the temporal arteries were tender or if the visual disturbance was clearly progressing, an earlier diagnosis would be easier.

Dr Steve Brown is a GP trainer in Beaconsfield, Buckinghamshire

key points key points

• Non tender pulsatile temporal arteries do not exclude temporal arteritis
• Think about the diagnosis in patients with a combination of visual disturbance (even transient), and scalp, face or jaw symptoms
• Obtain a clear history from patients with visual disturbances and do not dismiss ‘floaters'
• Refer for a second opinion if concerned, or obtain an urgent ESR
• Clearly explain to patients when they should return. In this case, for example, if the ‘floaters' were lasting for longer or becoming more frequent
• Work out how you organize extra appointments in your surgery to ensure that you are not too tired when you see them
• If possible, explore the reasons why patients who do not attend frequently have come to see you at that particular time. You may be surprised by the answers you receive

temporal arteritis temporal arteritis

early symptoms of temporal arteritis
* Unilateral headache, sometimes at the back of the head
* scalp sensitivity
* Jaw or face pain – jaw claudication is very highly suggestive of temporal arteritis
*Blurred vision, often transient
* Muscle aches and stiffness – 50% have polymyalgia rheumatica
* Temporal arteries may be non-tender and pulsatile
later symptoms of temporal arteritis
* General weakness and loss of appetite
* Double vision or acute loss of vision (ischaemic optic neuropathy or retinal artery occlusion)
* Weight loss
* Stroke from intracranial artery involvement

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