{"version":"1.0.0","segments":[{"startTime":3.165,"endTime":5.705,"body":"(Cathy) Hi, welcome to Harrison's Podclass"},{"startTime":5.705,"endTime":8.721,"body":"where we discuss important concepts"},{"startTime":5.705,"endTime":8.721,"body":"in Internal Medicine."},{"startTime":8.721,"endTime":9.831,"body":"I'm Cathy Handy..."},{"startTime":9.831,"endTime":11.911,"body":"(Charlie) I'm Charlie Wiener,"},{"startTime":9.831,"endTime":11.911,"body":"and we're coming to you"},{"startTime":11.911,"endTime":13.902,"body":"from The Johns Hopkins School of Medicine."},{"speaker":"(Cathy) Episode 11","startTime":15.803,"endTime":18.743,"body":"A 60-Year-Old with Headache"},{"speaker":"(Cathy) Episode 11","startTime":19.485,"endTime":21.515,"body":"(Charlie) Cathy, one of the hardest topics"},{"speaker":"(Cathy) Episode 11","startTime":21.515,"endTime":24.585,"body":"for clinicians to balance"},{"speaker":"(Cathy) Episode 11","startTime":21.515,"endTime":24.585,"body":"the common with the worrisome"},{"speaker":"(Cathy) Episode 11","startTime":24.585,"endTime":26.715,"body":"is a patient presenting with headache."},{"speaker":"(Cathy) Episode 11","startTime":26.715,"endTime":29.525,"body":"Today's question highlights"},{"speaker":"(Cathy) Episode 11","startTime":26.715,"endTime":29.525,"body":"some aspects of the history"},{"speaker":"(Cathy) Episode 11","startTime":29.525,"endTime":32.395,"body":"that may help clinicians"},{"speaker":"(Cathy) Episode 11","startTime":29.525,"endTime":32.395,"body":"make this distinction."},{"speaker":"(Cathy) Episode 11","startTime":32.395,"endTime":34.135,"body":"The question reads,"},{"speaker":"(Cathy) Episode 11","startTime":34.135,"endTime":36.825,"body":"\"In a 60-year-old patient"},{"speaker":"(Cathy) Episode 11","startTime":34.135,"endTime":36.825,"body":"complaining of headache,"},{"speaker":"(Cathy) Episode 11","startTime":36.825,"endTime":39.915,"body":"which of the following aspects"},{"speaker":"(Cathy) Episode 11","startTime":36.825,"endTime":39.915,"body":"of the history is worrisome"},{"speaker":"(Cathy) Episode 11","startTime":39.915,"endTime":42.785,"body":"and suggests the need"},{"speaker":"(Cathy) Episode 11","startTime":39.915,"endTime":42.785,"body":"for further evaluation?\""},{"speaker":"(Cathy) Episode 11","startTime":43.573,"endTime":46.783,"body":"Option A is, \"First severe headache.\""},{"speaker":"(Cathy) Episode 11","startTime":47.373,"endTime":50.843,"body":"Option B is, \"Onset after age 55.\""},{"speaker":"(Cathy) Episode 11","startTime":51.522,"endTime":54.972,"body":"Option C is, \"Pain associated"},{"speaker":"(Cathy) Episode 11","startTime":51.522,"endTime":54.972,"body":"with local tenderness.\""},{"speaker":"(Cathy) Episode 11","startTime":55.793,"endTime":59.153,"body":"Option D is, \"Subacute worsening"},{"speaker":"(Cathy) Episode 11","startTime":55.793,"endTime":59.153,"body":"over days or weeks.\""},{"speaker":"(Cathy) Episode 11","startTime":59.731,"endTime":62.591,"body":"And, option E is,"},{"speaker":"(Cathy) Episode 11","startTime":59.731,"endTime":62.591,"body":"\"All of the above are true.\""},{"speaker":"(Cathy) Episode 11","startTime":62.872,"endTime":66.412,"body":"(Cathy) Well, like you mentioned, Charlie,"},{"speaker":"(Cathy) Episode 11","startTime":62.872,"endTime":66.412,"body":"headache is a common concern"},{"speaker":"(Cathy) Episode 11","startTime":66.412,"endTime":68.732,"body":"and most of the time"},{"speaker":"(Cathy) Episode 11","startTime":66.412,"endTime":68.732,"body":"headaches aren't worrisome."},{"speaker":"(Cathy) Episode 11","startTime":68.732,"endTime":70.762,"body":"But it is important"},{"speaker":"(Cathy) Episode 11","startTime":68.732,"endTime":70.762,"body":"for internists to remember"},{"speaker":"(Cathy) Episode 11","startTime":70.762,"endTime":74.022,"body":"that there are certain signs or symptoms"},{"speaker":"(Cathy) Episode 11","startTime":70.762,"endTime":74.022,"body":"that should heighten one's concern"},{"speaker":"(Cathy) Episode 11","startTime":74.022,"endTime":76.222,"body":"that a more serious problem"},{"speaker":"(Cathy) Episode 11","startTime":74.022,"endTime":76.222,"body":"may be present."},{"speaker":"(Cathy) Episode 11","startTime":76.222,"endTime":78.552,"body":"For example, you mention in option A,"},{"speaker":"(Cathy) Episode 11","startTime":78.552,"endTime":80.992,"body":"a patient who presents"},{"speaker":"(Cathy) Episode 11","startTime":78.552,"endTime":80.992,"body":"with a new severe headache"},{"speaker":"(Cathy) Episode 11","startTime":80.992,"endTime":83.262,"body":"has a differential diagnosis"},{"speaker":"(Cathy) Episode 11","startTime":80.992,"endTime":83.262,"body":"that's quite different"},{"speaker":"(Cathy) Episode 11","startTime":83.262,"endTime":86.652,"body":"from the patient who presents"},{"speaker":"(Cathy) Episode 11","startTime":83.262,"endTime":86.652,"body":"with recurrent headaches over many years."},{"speaker":"(Cathy) Episode 11","startTime":87.3,"endTime":89.34,"body":"In a new onset and severe headache,"},{"speaker":"(Cathy) Episode 11","startTime":89.34,"endTime":92.0,"body":"the probability of finding"},{"speaker":"(Cathy) Episode 11","startTime":89.34,"endTime":92.0,"body":"a potentially serious cause"},{"speaker":"(Cathy) Episode 11","startTime":92.0,"endTime":94.64,"body":"is considerably greater"},{"speaker":"(Cathy) Episode 11","startTime":92.0,"endTime":94.64,"body":"than in recurrent headache."},{"speaker":"(Cathy) Episode 11","startTime":94.64,"endTime":97.89,"body":"And this is one example that"},{"speaker":"(Cathy) Episode 11","startTime":94.64,"endTime":97.89,"body":"definitely warrants further evaluation."},{"speaker":"(Cathy) Episode 11","startTime":97.89,"endTime":101.63,"body":"(Charlie) In those kinds of cases,"},{"speaker":"(Cathy) Episode 11","startTime":97.89,"endTime":101.63,"body":"what kind of causes do you think about?"},{"speaker":"(Cathy) Episode 11","startTime":101.63,"endTime":103.615,"body":"(Cathy) So I think mostly"},{"speaker":"(Cathy) Episode 11","startTime":101.63,"endTime":103.615,"body":"about meningitis,"},{"speaker":"(Cathy) Episode 11","startTime":103.615,"endTime":106.24,"body":"especially if there was fever"},{"speaker":"(Cathy) Episode 11","startTime":103.615,"endTime":106.24,"body":"or nuchal rigidity,"},{"speaker":"(Cathy) Episode 11","startTime":106.24,"endTime":109.91,"body":"subarachnoid hemorrhage"},{"speaker":"(Cathy) Episode 11","startTime":106.24,"endTime":109.91,"body":"or epidural or subdural hemorrhage."},{"speaker":"(Cathy) Episode 11","startTime":109.91,"endTime":112.95,"body":"Glaucoma I would think about too"},{"speaker":"(Cathy) Episode 11","startTime":109.91,"endTime":112.95,"body":"if there were ocular symptoms"},{"speaker":"(Cathy) Episode 11","startTime":112.95,"endTime":115.4,"body":"and then also purulent sinusitis."},{"speaker":"(Cathy) Episode 11","startTime":115.773,"endTime":118.833,"body":"The first step is always"},{"speaker":"(Cathy) Episode 11","startTime":115.773,"endTime":118.833,"body":"a careful neurologic examination."},{"speaker":"(Cathy) Episode 11","startTime":119.18,"endTime":121.33,"body":"(Charlie) What about"},{"speaker":"(Cathy) Episode 11","startTime":119.18,"endTime":121.33,"body":"some of the other choices?"},{"speaker":"(Cathy) Episode 11","startTime":121.337,"endTime":124.387,"body":"(Cathy) Option B mentions"},{"speaker":"(Cathy) Episode 11","startTime":121.337,"endTime":124.387,"body":"the onset after age 55,"},{"speaker":"(Cathy) Episode 11","startTime":124.387,"endTime":127.137,"body":"and that's also concerning"},{"speaker":"(Cathy) Episode 11","startTime":124.387,"endTime":127.137,"body":"because these patients are at high risk"},{"speaker":"(Cathy) Episode 11","startTime":127.137,"endTime":129.297,"body":"for dangerous causes of headache"},{"speaker":"(Cathy) Episode 11","startTime":127.137,"endTime":129.297,"body":"like hemorrhage"},{"speaker":"(Cathy) Episode 11","startTime":129.297,"endTime":133.297,"body":"and that's mostly due to a higher burden"},{"speaker":"(Cathy) Episode 11","startTime":129.297,"endTime":133.297,"body":"of risk factors like hypertension."},{"speaker":"(Cathy) Episode 11","startTime":133.591,"endTime":136.691,"body":"Option C, pain associated"},{"speaker":"(Cathy) Episode 11","startTime":133.591,"endTime":136.691,"body":"with local tenderness,"},{"speaker":"(Cathy) Episode 11","startTime":136.691,"endTime":138.891,"body":"makes me think of giant cell arteritis."},{"speaker":"(Cathy) Episode 11","startTime":138.891,"endTime":141.581,"body":"This is more common in elderly people"},{"speaker":"(Cathy) Episode 11","startTime":138.891,"endTime":141.581,"body":"and is really dangerous"},{"speaker":"(Cathy) Episode 11","startTime":141.581,"endTime":143.921,"body":"because if untreated can lead to blindness"},{"speaker":"(Cathy) Episode 11","startTime":143.921,"endTime":146.831,"body":"due to involvement"},{"speaker":"(Cathy) Episode 11","startTime":143.921,"endTime":146.831,"body":"of the ophthalmic artery and its branches."},{"speaker":"(Cathy) Episode 11","startTime":146.831,"endTime":150.221,"body":"You definitely don't want to miss this,"},{"speaker":"(Cathy) Episode 11","startTime":146.831,"endTime":150.221,"body":"because treatment with glucocorticoids"},{"speaker":"(Cathy) Episode 11","startTime":150.221,"endTime":153.131,"body":"is effective in preventing"},{"speaker":"(Cathy) Episode 11","startTime":150.221,"endTime":153.131,"body":"this complication if caught early."},{"speaker":"(Cathy) Episode 11","startTime":153.838,"endTime":156.868,"body":"Finally, Option D,"},{"speaker":"(Cathy) Episode 11","startTime":153.838,"endTime":156.868,"body":"if a headache continues to get worse,"},{"speaker":"(Cathy) Episode 11","startTime":156.868,"endTime":159.398,"body":"it should also prompt further evaluation."},{"speaker":"(Cathy) Episode 11","startTime":159.398,"endTime":162.618,"body":"The common benign causes of headache"},{"speaker":"(Cathy) Episode 11","startTime":159.398,"endTime":162.618,"body":"you wouldn't expect to last that long"},{"speaker":"(Cathy) Episode 11","startTime":162.618,"endTime":165.298,"body":"and you wouldn't expect it to worsen"},{"speaker":"(Cathy) Episode 11","startTime":162.618,"endTime":165.298,"body":"during that time period."},{"speaker":"(Cathy) Episode 11","startTime":165.683,"endTime":168.183,"body":"(Charlie) So, in terms"},{"speaker":"(Cathy) Episode 11","startTime":165.683,"endTime":168.183,"body":"of evaluating these cases,"},{"speaker":"(Cathy) Episode 11","startTime":168.183,"endTime":170.633,"body":"how does imaging with CT or MRI help?"},{"speaker":"(Cathy) Episode 11","startTime":171.073,"endTime":173.733,"body":"(Cathy) In most cases,"},{"speaker":"(Cathy) Episode 11","startTime":171.073,"endTime":173.733,"body":"patients with an abnormal neuro exam"},{"speaker":"(Cathy) Episode 11","startTime":173.733,"endTime":175.733,"body":"or with a history"},{"speaker":"(Cathy) Episode 11","startTime":173.733,"endTime":175.733,"body":"of recent onset headaches,"},{"speaker":"(Cathy) Episode 11","startTime":175.733,"endTime":178.683,"body":"should be evaluated"},{"speaker":"(Cathy) Episode 11","startTime":175.733,"endTime":178.683,"body":"with a radiology test quickly"},{"speaker":"(Cathy) Episode 11","startTime":178.683,"endTime":181.343,"body":"and usually CT or MRI"},{"speaker":"(Cathy) Episode 11","startTime":178.683,"endTime":181.343,"body":"are the ones that are used."},{"speaker":"(Cathy) Episode 11","startTime":181.779,"endTime":185.509,"body":"CT is usually the most accessible study"},{"speaker":"(Cathy) Episode 11","startTime":181.779,"endTime":185.509,"body":"to obtain first and quickly."},{"speaker":"(Cathy) Episode 11","startTime":185.912,"endTime":189.862,"body":"As an initial screening test,"},{"speaker":"(Cathy) Episode 11","startTime":185.912,"endTime":189.862,"body":"CT and MRI are about equally sensitive,"},{"speaker":"(Cathy) Episode 11","startTime":189.862,"endTime":192.392,"body":"but it's really helpful"},{"speaker":"(Cathy) Episode 11","startTime":189.862,"endTime":192.392,"body":"to discuss the clinical scenario"},{"speaker":"(Cathy) Episode 11","startTime":192.392,"endTime":194.802,"body":"and what your concerns are,"},{"speaker":"(Cathy) Episode 11","startTime":192.392,"endTime":194.802,"body":"with your radiologist"},{"speaker":"(Cathy) Episode 11","startTime":194.802,"endTime":197.162,"body":"to ensure that you're"},{"speaker":"(Cathy) Episode 11","startTime":194.802,"endTime":197.162,"body":"ordering the correct study."},{"speaker":"(Cathy) Episode 11","startTime":197.162,"endTime":201.162,"body":"For example, if there is suspicion"},{"speaker":"(Cathy) Episode 11","startTime":197.162,"endTime":201.162,"body":"of hemorrhage, a CT is preferred,"},{"speaker":"(Cathy) Episode 11","startTime":201.162,"endTime":203.212,"body":"whereas if the concern"},{"speaker":"(Cathy) Episode 11","startTime":201.162,"endTime":203.212,"body":"is something more subtle,"},{"speaker":"(Cathy) Episode 11","startTime":203.212,"endTime":206.732,"body":"such as multiple sclerosis,"},{"speaker":"(Cathy) Episode 11","startTime":203.212,"endTime":206.732,"body":"an MRI is going to be a better test."},{"speaker":"(Cathy) Episode 11","startTime":207.206,"endTime":210.446,"body":"(Charlie) Are there any symptoms"},{"speaker":"(Cathy) Episode 11","startTime":207.206,"endTime":210.446,"body":"that suggest a more serious"},{"speaker":"(Cathy) Episode 11","startTime":210.446,"endTime":214.386,"body":"rather than a benign cause of headache"},{"speaker":"(Cathy) Episode 11","startTime":210.446,"endTime":214.386,"body":"other than the ones"},{"speaker":"(Cathy) Episode 11","startTime":214.743,"endTime":218.693,"body":"(Cathy) So other symptoms"},{"speaker":"(Cathy) Episode 11","startTime":214.743,"endTime":218.693,"body":"that would worry me"},{"speaker":"(Cathy) Episode 11","startTime":218.693,"endTime":222.693,"body":"any pain that's induced"},{"speaker":"(Cathy) Episode 11","startTime":218.693,"endTime":222.693,"body":"by bending, lying down, or coughing,"},{"speaker":"(Cathy) Episode 11","startTime":222.693,"endTime":226.503,"body":"if there's pain that disturbs sleep"},{"speaker":"(Cathy) Episode 11","startTime":222.693,"endTime":226.503,"body":"or presents immediately upon wakening,"},{"speaker":"(Cathy) Episode 11","startTime":226.503,"endTime":229.383,"body":"and certainly if there's"},{"speaker":"(Cathy) Episode 11","startTime":226.503,"endTime":229.383,"body":"known systemic illness such as cancer"},{"speaker":"(Cathy) Episode 11","startTime":229.383,"endTime":232.093,"body":"or if the patient is immunosuppressed"},{"speaker":"(Cathy) Episode 11","startTime":229.383,"endTime":232.093,"body":"for other reasons."},{"speaker":"Other things that I think about","startTime":232.458,"endTime":237.298,"body":"If there's fever or unexplained"},{"speaker":"Other things that I think about","startTime":237.298,"endTime":240.458,"body":"And, of course,"},{"speaker":"Other things that I think about","startTime":237.298,"endTime":240.458,"body":"if there are any abnormalities"},{"speaker":"Other things that I think about","startTime":240.458,"endTime":243.478,"body":"I would definitely be worried"},{"speaker":"Other things that I think about","startTime":240.458,"endTime":243.478,"body":"and would want to do further testing."},{"speaker":"Other things that I think about","startTime":243.992,"endTime":246.082,"body":"(Charlie) So, before we finish,"},{"speaker":"Other things that I think about","startTime":243.992,"endTime":246.082,"body":"let's just go back"},{"speaker":"Other things that I think about","startTime":246.082,"endTime":247.347,"body":"to the issue of brain tumors,"},{"speaker":"Other things that I think about","startTime":247.347,"endTime":249.392,"body":"since that's often"},{"speaker":"Other things that I think about","startTime":247.347,"endTime":249.392,"body":"patients' biggest concern"},{"speaker":"Other things that I think about","startTime":249.392,"endTime":251.912,"body":"and what they will come and ask about"},{"speaker":"Other things that I think about","startTime":249.392,"endTime":251.912,"body":"when they come to clinic."},{"speaker":"Other things that I think about","startTime":251.912,"endTime":253.922,"body":"(Cathy) So you definitely can hear that."},{"speaker":"Other things that I think about","startTime":253.922,"endTime":256.462,"body":"But fortunately brain tumors"},{"speaker":"Other things that I think about","startTime":253.922,"endTime":256.462,"body":"are a rare cause of headaches"},{"speaker":"Other things that I think about","startTime":256.462,"endTime":259.542,"body":"and they are very uncommon"},{"speaker":"Other things that I think about","startTime":256.462,"endTime":259.542,"body":"to cause severe pain."},{"speaker":"Other things that I think about","startTime":259.987,"endTime":263.047,"body":"(Charlie) So therefore"},{"speaker":"Other things that I think about","startTime":259.987,"endTime":263.047,"body":"the answer to this question is \"E.\""},{"speaker":"Other things that I think about","startTime":263.047,"endTime":266.357,"body":"All of the above that I mentioned before"},{"speaker":"Other things that I think about","startTime":263.047,"endTime":266.357,"body":"are signs or symptoms"},{"speaker":"Other things that I think about","startTime":266.357,"endTime":269.717,"body":"that are worrisome for a possible"},{"speaker":"Other things that I think about","startTime":266.357,"endTime":269.717,"body":"severe cause of headache"},{"speaker":"Other things that I think about","startTime":269.717,"endTime":272.167,"body":"and merit further evaluation."},{"speaker":"Other things that I think about","startTime":272.167,"endTime":274.777,"body":"The teaching point is"},{"speaker":"Other things that I think about","startTime":272.167,"endTime":274.777,"body":"that the history will often guide you"},{"speaker":"Other things that I think about","startTime":274.777,"endTime":278.947,"body":"towards distinguishing"},{"speaker":"Other things that I think about","startTime":274.777,"endTime":278.947,"body":"between a serious or a more benign"},{"speaker":"Other things that I think about","startTime":278.947,"endTime":281.557,"body":"and furthermore, collaboration"},{"speaker":"Other things that I think about","startTime":278.947,"endTime":281.557,"body":"with your radiologist"},{"speaker":"Other things that I think about","startTime":281.557,"endTime":285.557,"body":"can also help guide your evaluation"},{"speaker":"Other things that I think about","startTime":281.557,"endTime":285.557,"body":"and your diagnostic workup."},{"speaker":"Other things that I think about","startTime":286.023,"endTime":289.083,"body":"(Cathy) For more information about"},{"speaker":"Other things that I think about","startTime":286.023,"endTime":289.083,"body":"the differential diagnosis of headache,"},{"speaker":"Other things that I think about","startTime":289.083,"endTime":291.973,"body":"check out the Harrison's chapter"},{"speaker":"Other things that I think about","startTime":289.083,"endTime":291.973,"body":"on cardinal manifestations"},{"speaker":"Other things that I think about","startTime":291.973,"endTime":294.553,"body":"and presentation of disease."}]}