One major difference between treating patients in the emergency department (ED) and the private office is the availability of the clinical laboratory. In the private office setting, it is not uncommon to have a patient present with headaches with attendant temple tenderness. It is unlikely that a patient with this presentation would be referred out for laboratory testing before treatment of a suspected tension headache.
The patient in the following example believed he only needed a CT scan to rule out a brain tumor, and strong pain medication to relieve his headache. He was resistant to having blood drawn in the ED or being admitted, even after it was determined his condition was potentially more serious than he was willing to accept. This case history demonstrates both the experience that can be gained by the chiropractor working in the ED, and the contribution a DC can offer to a patient suffering from multiple, overlapping disorders.
The patient, a 56-year-old Caucasian male, reported to the ED complaining of neck pain and headaches. Ten days earlier, he had been struck on the forehead by a baseball; at the time, he felt dazed, suffered no loss of consciousness. Approximately one week later, he developed neck pain after carrying a travel bag with the strap over his shoulder. He complained that the neck pain spread to the left axillary pectoral junction.
The patient denied radiation of pain or paresthesia to his upper limbs. He said his bilateral cervical rotation was restricted. He complained of left sternocleidomastoideus pain during chewing and when extending his neck. At the same time the neck pain started, the patient began to feel a throbbing pain in his temples. He indicated that occipital pain had worsened with cervical extension and prevented him from sleeping, and that it increased if he pressed the back of his head against something (such as a seat back).
The patient denied nausea, vomiting, dizziness or visual scotoma. He reported that he had temporary, but limited, relief through self-medication with Tylenol or Excedrin. He claimed he had tried all of the available over-the-counter pain relievers without adequate relief of his headaches; he denied a long history of their frequency. The patient said this particular headache was the longest and most intense episode he had experienced in his life. He went on to say that he had an appointment with his chiropractor the following morning, but the pain was too intense for him to wait another night. He also reported noticing that his cheeks had appeared red for the past several weeks.
The patient's past medical history was noncontributory to diagnosis. Systems review was negative, except for the need to medicate for non-insulin-dependent diabetes. His serum glucose was within normal limits. Family history included both parents dying from cardiovascular disease and his brother dying from lung cancer.
Palpation of both temples elicited verbalization of tenderness, and complaints of tenderness of the left cervical paraspinal muscle, sternocleidomastoideus muscle and mastoid process. Motion palpation revealed severe cervical vertebral joint fixation. Cervical compression maneuvers were negative, and cervical distraction increased the patient's pain. Adson's test was negative bilaterally; Valsalva's maneuver was negative. The patient denied difficulty or pain with swallowing. He was neurologically intact with +5/5 upper-limb strength; +2/2 bilateral upper-limb deep tendon reflexes; and equal bilateral upper-limb dermatome sensation. A reddish butterfly-pattern discoloration was present across his cheeks.
Laboratory testing revealed an elevated erythrocyte sedimentation rate (ESR). Due to the combination of temporal headaches; age greater than 50 years; tender temporal arteries; and elevated ESR, a working diagnosis of temporal arteritis was made. The patient was admitted to the hospital for treatment with steroids and biopsy of the temporal arteries. Due to the red butterfly rash, a rheumatology consultation was ordered to rule out lupus as the underlying cause of temporal arteritis. The patient was also diagnosed with a concomitant acute spasmodic torticollis that was treated with chiropractic care, consisting of manual muscle techniques and manual traction. Cervical adjustments were deferred, due to the patient's intolerance to rotation of his neck to the end-range of joint motion.
To review, the patient's history included trauma to his head; irritation of his upper trapezius by a shoulder strap; and prolonged sitting on an airplane. He had a history of controlled diabetes and a family history that included both parents dying from cardiovascular disease. In addition, he presented with tenderness of the temporal arteries and the butterfly rash characteristic of lupus. While temporal arteritis led the list in the differential diagnosis of his headaches, concomitant musculoskeletal-related cephalgia was also considered.
Patients suspected of suffering from temporal arteritis require immediate bloodwork, including an ESR. Patients suffering from untreated temporal arteritis risk blindness and stroke. If the ESR is elevated, the patient needs to be referred for medical treatment with steroids and biopsy of the temporal artery. In the ED, our patient was able to receive chiropractic treatment for his acute torticollis and cervical tension cephalgia shortly after presenting to us. At the same time, the attending ED physician was able to concentrate on addressing his more health-threatening and less symptomatic temporal arteritis and suspected lupus. The patient was advised to follow-up with his private chiropractor after being released from the hospital.
John Cerf, DC
Jersey City, New Jersey
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