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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2892_Библиотеки_им_академика_М_И_Перельмана
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33.2 A patient with a BMI of 35 kg/m2 whom you have been seeing for 10 years
recently lost his job as a truck driver due to uncontrolled obstructive sleep
apnea and need for insulin to control his diabetes. He states that he does not
really think that he is “fat.” For which of the following patients is a BMI measurement most likely to be an accurate assessment of obesity?
A. A bodybuilder with a BMI of 38 kg/m
2
B. A pregnant woman with a BMI of 31 kg/m2 in her 37th week of gestation
C. A man with congestive heart failure, pitting edema, and a BMI of 30 kg/m
D. A hypertensive woman with a BMI of 32 kg/m
2
33.3 A 34-year-old woman comes to your clinic to discuss weight management.
She is currently 5 ft 2 inches and 265 lb. She says she always had a hard time
managing her weight as a child, but she let things get out of control when she
was living on her own in college. She has had two children in the past 5years.
With her first child, she gained 50 lb during the pregnancy and lost 30lb after
delivery. With the second child, she gained 35 lb and lost 10lb. She has tried
many diets where she initially loses weight but eventually gains the weight
back. She exercises some but is limited by osteoarthritis of the knees. She has
thought about gastric bypass but is fearful of undergoing a surgical procedure. Which of the following medications is the best option for the long-term
management of her obesity?
A. Orlistat
B. Phendimetrazine
C. Dextroamphetamine
D. Phentermine
2
ANSWERS
33.1 C. The best evidence for bariatric surgery is for people with a BMI of greater
than 40 kg/m2 who have failed diet and exercise (with or without drug
therapy), or those with a BMI of greater than 35 kg/m2 and obesity-related
complications. Answer A (BMI of 32 kg/m2 and knee arthritis) is not an indication since the BMI is not > 35 kg/m2. Patients with grade I obesity with
diabetes mellitus (answer B) or significant medical conditions can be considered for bariatric surgery, but the evidence of benefit over risk is less robust.
Bariatric surgery can be effective but carries significant risks and should not
automatically be offered to all obese patients who request it (answer D).
33.2 D. A BMI reading will not accurately assess the ratio of lean body mass to body
fat in highly muscled persons such as weightlifters and athletes (answerA),
persons with decreased muscle mass such as the elderly population, pregnant
women because of the enlarged uterus and fetus (answerB), and patients with
symptomatic congestive heart failure due to the pedal edema (answerC).
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33.3 A. Orlistat is indicated for the long-term treatment of obesity. The mechanisms of this agent are as a lipase inhibitor and decreasing fat absorption.
Orlistat promotes weight loss and leads to about a 2- to 3-kg loss over a year.
All of the pure stimulant medications (answer B, phendimetrazine; answer C,
dextroamphetamine; and answer D, phentermine) should be for short-term
use only.
CLINICAL PEARLS
» Obesity is a chronic disease that is reaching epidemic status in the
UnitedStates and worldwide.
» Body mass index is a common tool used to grade obesity, but in certain
cases it may be inadequate.
» Obesity treatment should always include dietary modifications and
portion control, increased activity, and behavioral modifications.
» Even 5% to 15% weight loss can significantly reduce the complications
associated with obesity.
REFERENCES
Curry SJ, Krist AH, Owens DK, et al. US Preventive Services Task Force. Behavioral weight loss
interventions to prevent obesity-related morbidity and mortality in adults: US Preventive
Services Task Force recommendation statement. JAMA. 2018;320(11):1163-1171. doi:10.1001/
jama.2018.13022.
Flier JS, Maratos-Flier E. Pathobiology of Obesity. In: Jameson J, Fauci AS, Kasper DL, Hauser
SL, Longo DL, Loscalzo J. eds. Harrison’s Principles of Internal Medicine, 20th ed. Ne w Yor k,
NY: McGraw Hill. http://accessmedicine.mhmedical.com/content.aspx?bookid=2129§ionid=
192288213. Accessed May 21, 2020.
Garvey WT, Mechanick JI, Brett EM, et al; American Association of Clinical Endocrinologists/American
College of Endocrinology (AACE/ACE) Comprehensive Clinical Practice Guidelines for Medical
Care of Patients with Obesity. Endocr Pract. 2016.
Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of Obesity Among Adults and Youth:
United States, 2015–2016. Hyattsville, MD: National Center for Health Statistics; 2017. NCHS
data brief, no 288.
Moore JX, Chaudhary N, Akinyemiju T. Metabolic syndrome prevalence by race/ethnicity and sex in
the United States, National Health and Nutrition Examination Survey, 1988–2012. Prev Chronic
Dis. 2017;14:160287.
Moyer VA; US Preventive Services Task Force. Screening for and management of obesity in adults:
US Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(5):
373-378.
Via MA, Mechanick JI. Chapter 26. Metabolic Syndrome. In: Fuster V, Harrington RA, Narula J,
Eapin ZJ. eds. Hurst’s The Heart, 14th ed. New York, NY: McGraw Hill; 2017.
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CASE 34
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A 33-year-old woman presents with a complaint of headaches. She has had
headaches since she was a teenager, but they have become more debilitating
recently. The episodes occur once or twice each month and last for up to 2 days.
The pain begins in the right temple or at the back of the right eye and spreads
to the entire scalp over a few hours. She describes the pain as a sharp, throbbing
sensation that gradually worsens and is associated with severe nausea. Several
factors aggravate the pain, including loud noises and movement. She has taken
several over-the-counter (OTC) medications for the pain, but the only thing that
works is going to sleep in a quiet, darkened room. A thorough history reveals
that her mother suffers from migraine headaches. Her vital signs, general
physical examination, and a thorough neurologic examination are all within
normal limits.
▶ What is the most likely diagnosis?
▶ What imaging study is most appropriate at this time?
▶ What are the most appropriate therapy?
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ANSWERS TO CASE 34:
Migraine and Other Headache Syndromes
Summary: A 33-year-old woman presents with
Headaches that have occurred since she was a teenager and have progressively
worsened
Right-sided, throbbing headaches and nausea that worsen with loud noises and move-
ment and are relieved by sleeping in a dark, quiet room
No relief from headaches from OTC preparations
Family history of migraines in mother
Vital signs, general physical examination, and thorough neurologic examination that
are all within normal limits
Most likely diagnosis: Migraine without aura.
Most appropriate imaging study: No imaging is indicated at this time since there are
no “red flag” symptoms or signs.
Most appropriate therapy: A “triptan” medication given in a means that does not
have to be swallowed (subcutaneous, intranasal, or orally dissolving tablet).
ANALYSIS
Objectives
1. State a differential diagnosis for chronic headaches. (EPA 2)
2. List the red flag symptoms and signs that should prompt rapid, specific diagnostic and treatment interventions. (EPA 1, 10)
3. Describe the management of common headache syndromes. (EPA 4)
Considerations
The patient described in the case has symptoms that are very characteristic of
migraine without aura. Her headaches are unilateral, throbbing in nature, and
have been progressively worsening. Migraines typically cause recurrent episodes of
headache, nausea, and vomiting. They can also be associated with other neurologic
symptoms, such as photophobia, lightheadedness, paresthesias, vertigo, and visual
disturbances. In the patient described in this case, the history and lack of physical findings can reasonably lead to the diagnosis of migraine headaches without
aura (“common migraine”), the most frequently occurring form. Other classifications of migraines include migraine with aura (“classic migraine”), ophthalmoplegic
migraine, retinal migraine, and childhood periodic syndromes that may be precursors to or associated with migraines. During the evaluation of this patient, the
focus should be on determining the etiology of the headache, assessing for any red
flags that may indicate worse pathologic causes, identifying triggers, and determining appropriate therapy for the condition.
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According to the International Headache Society, symptoms diagnostic of
migraine headache include moderate-to-severe headache with a pulsating quality;
unilateral location; nausea and/or vomiting; photophobia; phonophobia; worsening with activity; multiple attacks lasting from 4 hours to 3 days; and absence of
history or physical examination findings that would make it likely that the headache is the result of another cause.
APPROACH TO:
Migraine and Other Headache Syndromes
DEFINITIONS
CHRONIC DAILY HEADACHE: Experiencing headache on 15 days or more per
month. Chronic daily headache (CDH) is not a single entity; it can encompass a
number of headache syndromes, including chronic tension headaches, migraines,
infection, inflammation, trauma, and medication overuse.
CLUSTER HEADACHE: Unilateral headaches that may have a high male predominance; can be located in the orbital, supraorbital, or temporal region. Pain is
generally described as deep and excruciating, lasting from 15 minutes to 3 hours.
These headaches are usually episodic; however, a small subset may have chronic
headaches.
MIGRAINE HEADACHES: Vascular headaches typically throbbing and unilateral in character; may be present with or without an aura. There is a high female
predominance.
PRIMARY HEADACHE SYNDROME: Syndrome in which headache and associated features occur in the absence of any exogenous cause. The most common are
migraine, tension-type headache, and cluster headache.
TENSION HEADACHE: The most common primary headache syndrome, typically presenting with pericranial muscle tenderness and a description of a bilateral
band-like distribution of the pain.
CLINICAL APPROACH TO MIGRAINES
Pathophysiology
Headaches are an extremely common complaint in primary care, urgent care, and
emergency settings. The vast majority of adults have at least one headache each
year, although most do not present for medical care. Migraine headaches are the
most common headaches of vascular origin and the second most common cause
of headaches overall. Migraines are a member of a group of primary headache syndromes differentiated by their associated features. Diagnostic criteria for migraine
headaches are listed in Table 34–1.
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Table 34–1 • SIMPLIFIED DIAGNOSTIC CRITERIA FOR MIGRAINE
Repeated attacks of headache lasting 4-72 h in patients with a normal physical examination,
no other reasonable cause for the headache, and
At Least 2 of the Following Features: Plus at Least 1 of the Following Features:
Unilateral pain Nausea/vomiting
Throbbing pain Photophobia and phonophobia
Aggravation by movement
Moderate or severe intensity
Adapted from the International Headache Society Classification (Headache Classification Committee of the International
Headache Society, 2004).
Functional limitations during headaches will determine the categorization of
the migraine and the choice of treatment (see Table 34–2). Clinicians should stratify treatment based on severity rather than using stepped care.
The role of the practitioner is to attempt to accurately diagnose the cause of the
headache, rule out secondary causes of headaches (“red flags”) that may signify a serious underlying pathology, provide appropriate acute management, and assist with
headache prevention when needed. It is important that each individual headache
be evaluated in the context of the patient’s prior headaches. The clinician should
remain alert to the possibility of a secondary cause for the headache. Migraine
headaches do not preclude the presence of underlying pathology.
Clinical Presentation
History. The medical history in a patient with headaches should focus on several
important areas. The quality and characteristics of the headache and its specific
location and radiation should be identified. The presence and extent of associated
symptoms, especially neurologic symptoms that may suggest the presence of a focal
neurologic lesion or increased intracranial pressure, must be documented. The age
at which the patient first developed the headaches, the frequency and duration
of the headaches, and the amount of disability and distress that is caused to the
patient should be explored. It is also important to note what the patient has done
to try to treat the headaches in the past, including as much detail as possible regarding medication usage (both prescription and OTC).
Physical Examination. The examination should include both a general examination and a detailed neurologic examination. A fundoscopic examination revealing
papilledema may be supportive of the presence of increased intracranial pressure.
Table 34–2 • MIGRAINE SEVERITY LEVELS
Mild Patient is aware of a headache but able to continue daily routine.
Moderate The headache inhibits daily activities but is not incapacitating.
Severe The headache is incapacitating.
Status A severe headache that has lasted more than 72 h.
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Table 34–3 • “RED FLAG” SYMPTOMS AND SIGNS IN THE EVALUATION
OF HEADACHES
Red Flag Differential Diagnosis Workup Studies
Sudden-onset maximum
severity “worst headache” or
new and different headache
Headaches increasing in
severity and frequency,
brought on by Valsalva or
physical exertion
Headache beginning after
age 50, especially if jaw pain
on chewing (jaw claudication)
New-onset headache in
patient with risk factors for HIV
infection or cancer
Headache with signs of
systemic illness (fever, stiff
neck, rash)
Focal neurologic signs or
symptoms of disease (other
than typical aura)
Papilledema Mass lesion, pseudotumor
Headache subsequent to
head trauma
Subarachnoid hemorrhage,
pituitary apoplexy,
hemorrhage into a mass
lesion or vascular
malformation, mass lesion
Mass lesion, subdural
hematoma, medication
overuse
Temporal arteritis, mass lesion Neuroimaging, erythrocyte
Meningitis, brain abscess
(including toxoplasmosis),
metastasis
Meningitis, encephalitis, Lyme
disease, systemic infection,
collagen vascular disease
Mass lesion, vascular
malformation, stroke, collagen
vascular disease
cerebri, meningitis
Intracranial hemorrhage,
subdural hematoma, epidural
hematoma, posttraumatic
headache
Neuroimaging first; lumbar
puncture if neuroimaging
negative
Neuroimaging, drug screen
sedimentation rate level
Neuroimaging first; lumbar
puncture if neuroimaging
negative
Neuroimaging, lumbar
puncture, serology
Neuroimaging, collagen
vascular evaluation (including
antiphospholipid antibodies)
Neuroimaging, lumbar
puncture
Neuroimaging of brain, skull,
and cervical spine
Data from South-Paul JE, Matheny SC, Lewis EL, et al. Current Diagnosis and Treatment in Family Medicine. 2004.
Copyright © McGraw Hill LLC. All rights reserved.
Identifying a focal neurologic deficit increases the likelihood of finding a significant
central nervous system pathology as the cause of the headache.
Imaging. A patient with symptoms and signs consistent with migraine who does
not have any red flag findings (see Table 34–3) does not require any further testing
prior to instituting treatment. Neuroimaging should be performed if there is an
unexplained neurologic abnormality on examination or if the headache syndrome
is not typical of either migraines or some other primary headache disorder. The
presence of rapidly increasing headache frequency or a history of lack of coordination,
focal neurologic symptom, or headache awakening the patient from sleep raises the
likelihood of finding an abnormality on an imaging test. Magnetic resonance imaging
may be more sensitive than computed tomography (CT) scanning for the identification of abnormalities, but it may not be more sensitive at identifying significant
abnormalities. CT scan would be the initial imaging for “thunderclap” headaches
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where intracranial bleeds are considered. Other testing (eg, blood tests, electroencephalogram) should only be performed for diagnostic purposes if there is a suspicion based on the history or physical examination.
Treatment
The treatment of headache is best individualized based on a thorough history,
physical examination, and the interpretation of any additional study results.
Nonpharmacologic Treatment. Migraines can often be managed to some degree
by a variety of nonpharmacologic approaches. Nonpharmacologic treatment can
include patient education, bed rest in a dark room, and removal of known triggers.
Most patients benefit from simple avoidance of specific headache triggers. Lifestyle
modifications may be helpful. These could include diet changes, regular exercise,
regular sleep patterns, avoidance of excess caffeine and alcohol, and avoidance of
acute changes in stress levels. Migraine patients do not encounter more stress or
triggers than the general population; however, they may have overresponsiveness
to these triggers.
First-line Medications. First-line therapies for mild-to-moderate migraines
include oral nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen.
Triptans are used as a first-line agent for moderate-to-severe migraines. Triptans
come in a variety of forms (oral, sublingual, subcutaneous), and patients may demonstrate responsiveness to one triptan but not to others.
Second-line Medications. Second-line therapies for migraines include intranasal
dihydroergotamine and opioids. Antiemetics, such as prochlorperazine or metaclopramide, can also be used. For refractory migraines, intravenous dihydroergotamine
can be used as long as a triptan was not administered in the preceding 24 hours.
Intravenous magnesium, valproic acid, and dexamethasone are other alternatives.
Treating Children and Pregnant Women. Pregnant women with migraines can
use a combination of acetaminophen and metoclopramide (which are the only safe
options in pregnancy). In children who experience migraines, ibuprofen and acetaminophen can be used. Certain triptans (rizatriptan, sumatriptan, and almotriptan) can be considered in children as well.
Chronic migraines (more than two or three migraines per week) may require
daily prophylaxis with beta-blockers, calcium channel blockers, amitriptyline, or
topiramate. Options for pharmacologic treatment and prophylaxis of migraines are
listed in Tables 34–4 and 34–5, respectively.
CLINICAL APPROACH TO OTHER HEADACHE SYNDROMES
Tension-Type Headache
Clinical Presentation. Tension headache is the most prevalent form of primary
headache disorder, typically presenting with pericranial muscle tenderness and a
description of a bilateral band like distribution of the pain. Headaches can last
from 30minutes to 7 days, and there is no aggravation by routine physical activity. There is no associated nausea or vomiting. Photophobia and phonophobia
are both absent, or one, but not the other, is present. They can be either episodic
(< 180 days/year) or chronic (> 180 days/year).
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Table 34–4 • TREATMENT OF ACUTE MIGRAINE
Drug Trade Name Dosage
I. Simple Analgesics
Acetaminophen, aspirin,
caffeine
II. NSAIDs
Naproxen Aleve, Anaprox,
Ibuprofen Advil, Motrin,
Tolfenamic acid Clotam Rapid 200 mg orally; may repeat ×1 after 1-2 h
Diclofenac potassium Cambia 50 mg orally (powder packet mixed
III. 5-HT1 Receptor Agonists
• Oral
Ergotamine 1 mg,
caffeine 100 mg
Naratriptan Amerge 2.5-mg tablet at onset; may repeat
Rizatriptan Maxalt
Sumatriptan Imitrex 50- to 100-mg tablet at onset; may repeat
Frovatriptan Frova 2.5-mg tablet at onset; may repeat after
Almotriptan Axert 12.5-mg tablet at onset; may repeat
Eletriptan Relpax 40 or 80 mg
Zolmitriptan Zomig
• Nasal
Dihydroergotamine Migranal Nasal
Sumatriptan Imitrex Nasal Spray 5-20 mg intranasal spray as 4 sprays of
Zolmitriptan Zomig 5-mg intranasal spray as 1 spray (may
Excedrin Migraine Two tablets or caplets every 6 h
(max 8per day)
220-550 mg orally twice daily
generic
400 mg orally every 3-4 h
Nuprin, generic
with water)
Cafergot One or two tablets at onset, then
one tablet every ½ h (max 6 per day,
10 per week)
once after 4 h
5- to 10-mg tablet at onset; may repeat
Maxalt-MLT
Zomig Rapimelt
Spray
after 2 h (max 30 mg/d)
after 2 h (max 200 mg/d)
2h (max 5 mg/d)
after 2 h (max 25 mg/d)
2.5-mg tablet at onset; may repeat
after 2h (max 10 mg/d)
Prior to nasal spray, the pump must be
primed 4 times; 1 spray (0.5 mg) is
administered, followed in 15 min by a
second spray
5mg or a single 20-mg spray (may repeat
once after 2 h, not to exceed a dose of
40mg/d)
repeat once after 2 h, not to exceed a
dose of 10 mg/d)
(Continued)
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