Migraine

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Greeting

Good day, dear Professor Doctor …,

I would now like to present the patient Susanne Holst to you.

She is 37 years old, 1.76 m tall and weighs about 71 kg. The body mass index (BMI) is 22.9, which is within the normal range.

Current history

The patient presented to us because of a slowly onset, since yesterday, pulsating left-sided headachen. The pain is, according to her report, localized in the temporal region and retroorbital and has intensified.

and has increased.

She rated the pain intensity as 7 out of 10.

The patient also noticed the following accompanying symptoms: photophobia, phonophobia, nausea as well as two episodes of emesis with food remnants, tachycardia, dizziness and paresthesia at the fingertips of the left hand (before and during the attack).

As aura she reported flashes of light in the left visual field, which occurred about 20 minutes before the onset of the headache.

The following clinical signs were not observed: pyrexia, consciousness disturbances, speech disturbances, pareses, epileptic seizures, chest pain, dyspnea, traumatic brain injury, restlessness, palpitations, lacrimation, rhinorrhea, facial hyperhidrosis pressure sensation or pain on pressing over the maxillary sinus or frontal sinus.

She stated that she has had similar, but milder headaches without vomiting for 10 years.

She reported that the headaches began after prolonged gardening in a stooped position while planting flower bulbs during simultaneously warm, dry föhn weather conditions.

Autonomic history

In the autonomic history there was insomnia in the form of difficulty falling asleep due to the headaches as well as occasional sleep disturbances due to nocturnal coughing episodes with known bronchial asthma.

Previous illnesses

Her known past medical history includes the following:

A bronchial asthmawhich she has had since school age. Triggering factors included grass pollen, especially in the spring and summer months.

Occasionally she suffers from herpes labialis on the lower lip, which typically occurs during periods of stress or with fever.

For about four years the patient has had a cervical disc prolapse at the level between the fifth and sixth cervical vertebra. Since then she has occasionally experienced neck pain radiating to the right shoulder.

She also had about five years ago, as a result of a car accident, a right rib contusion which was treated conservatively. (She reported that she had been sitting in the front passenger seat of her mother’s car, who had to brake sharply because a cyclist suddenly appeared.)

Previous operations

The patient’s surgical history includes the following procedures:

About 20 years ago she underwent an appendectomy due to a perforated appendicitis with subsequent peritonitis .

In addition, about 10 years ago she underwent a right oophorectomy for an

Both procedures were performed laparoscopically.

gynecology

Gynecology

The patient reported having a regular cycle (every 30 days); her last menstruation occurred one week ago.

She currently has no gynecological complaints.

Medications

Medications

According to her own report, the patient is currently taking the following medications:

Ibuprofen 400 mg as needed

• acyclovirointment

• salbutamol

• a patch for cervical pain

Allergies

The patient reported the following allergies and intolerances:

Hazelnuts and walnuts with flatulence
fructose intolerance to grapes and ripe pears, with abdominal pain and diarrhea
Nickel allergy with erythema and pruritus

Noxae

In the noxae history the patient stated that she has been a non-smoker for 10 years, but previously smoked about 10 cigarettes daily for three years, corresponding to 1.5 pack-years.
She also drinks wine occasionally and denied drug use.

Social history

In the social history the patient reported that she works as a presenter for ZDF. She is married and lives with her husband; she has no children.

Family history

Her father was diagnosed with a brain tumor at the age of 70 and died nine months later from it.
Her mother received a hip total endoprosthesis for advanced osteoarthritis on the right at the age of 60.
In addition, an aunt of the patient suffers from migraine.

Suspected and differential diagnosis

The anamnestical information – including aura, character, duration and localization of the pain – most likely indicate a migraine with aura.

Cluster headache would be expected to show autonomic accompaniments (Horner syndrome, lacrimation, rhinorrhea).

The absence of fever and neck stiffness argues against meningitis.

The absence of fever and of pain in the area of the paranasal sinuses argues against sinusitis.

In a subarachnoid hemorrhage we expect an acute-onset, rapidly maximal headache (“thunderclap headache”).

Tumors typically show a chronically progressive course, where headaches can worsen with Valsalva maneuvers and may be accompanied by neurological deficits.

Tension-type headache

Migraine

Cluster

Localization

bilateral: frontal/ occipital

unilateral: temporofrontal

unilateral: retroorbital point

Character

pressing/ dull

throbbing/ pulsating

Intensity

mild to moderate

severe

extremely severe

Associated symptoms

Aura, nausea, emesis, photophobia, phonophobia

Ptosis, Miosis, Rhinorrhea, Eyelid edema, Lacrimation

Duration

Hours to days

Hours to days

Minutes to hours

Improvement with activity

+

–

Epidemiology

Men = Women

Men < Women

Men > Women

Diagnostic workup

Physical examination

Because no improvement occurred with self-medication and nausea as well as two episodes of vomiting were present, making oral medication intake impossible, the patient was admitted to the hospital.

(An unclear cause (for example with pathological neurological findings) clearly argues for inpatient evaluation – especially to exclude secondary causes of headache.)

After the medical history, a thorough physical examination is performed. This begins with measuring vital signs, including heart rate, blood pressure, respiratory rate, oxygen saturation and body temperature.

This is followed by a targeted physical examination, starting with inspection. The patient may appear tired, pale, or stressed. Palpation of the head and neck region is usually unremarkable – except when giant cell arteritis is suspected, in which case there may be tenderness over the temporal arteries. Percussion has no immediate diagnostic value in this context. Auscultation is not required for the diagnosis of migraine but can be used additionally to assess cardiovascular status. Giant cell arteritis, where there may be pressure tenderness of the temporal arteries. Percussion has no immediate diagnostic value in this context. Auscultation is not necessary for the diagnosis of migraine, but can be used additionally to assess cardiovascular status.

Assess neurological abnormalities: a focal neurological deficit could indicate stroke or a CNS lesion.

A neurological examination should follow, especially to assess cranial nerve function (pupillary reaction, eye movements, facial motor function), sensation (e.g., by touch or pressure stimuli) as well as motor function (strength, muscle tone, active and passive range of motion, coordination, reflexes). A fundoscopy is essential to exclude a possible papilledema .

Cranial nerve function in detail:

N. olfactorius (I): olfactory nerve

N. optic (II): Optic nerve

N. oculomotor (III), N. trochlear (IV), N. abducens (VI): Eye movement nerves

N. trigeminal (V): Facial sensation and masticatory muscles

N. facial (VII): Facial muscles, taste

N. vestibulocochlear (VIII): Hearing and balance

N. glossopharyngeal (IX): Taste, swallowing reflex

N. vagus (X): Parasympathetic innervation of the viscera

N. accessory (XI): Shoulder and neck muscles

N. hypoglossal (XII): Tongue movement

A CNS infection (e.g., meningitis/encephalitis) can also trigger seizures and must be considered in the presence of fever, meningism or altered consciousness.

Laboratory tests

If the headache is clinically typical for migraine and the neurological findings remain unremarkable, no further diagnostic measures are required.

If meningitis is suspected, a cerebrospinal fluid examination should be performed to confirm the diagnosis.

Further investigations

Imaging procedures are particularly necessary when certain warning signs are present – for example a sudden and abrupt onset headache (“thunderclap headache”) within seconds, new-onset headache in patients over 50 years old, papilledema, or headaches that are worsened by coughing, sneezing or the Valsalva maneuver .

Computed tomography

Computed tomography (CT) is an imaging technique that uses X-rays to create detailed cross-sectional images of internal organs. The patient is moved into a tubular scanner and must lie still during the examination. Sometimes a contrast agent is administered to allow a more precise depiction. The examination is painless and takes only a few minutes. Before a contrast-enhanced examination it is important that you drink enough fluids. We should also determine kidney function. Certain medications such as metformin should be paused beforehand – we will clarify that with you. In rare cases an allergic reaction to the contrast agent can occur, but do not worry: we are prepared and have all necessary medications and measures on site.

Intracerebral hemorrhages appear on cranial CT as hyperdense areas, i.e., as bright (white) spots. In contrast, ischemic infarcts in stroke typically appear hypodense on CT, i.e., as dark (gray to black) areas.

MRI (magnetic resonance imaging)

An MRI is an imaging technique that uses magnetic fields and radio waves to create detailed images of organs, tissues and structures in the body. The patient must first remove jewelry and other metallic objects and is then moved into a tubular scanner. In addition, the patient must inform us about any implants or a pacemaker before the examination. During the examination, which lasts about 20–60 minutes, the patient must lie still. In some cases contrast agent may be administered to better depict certain structures. Administration of contrast agent carries the risk of allergic reactions or contrast-induced kidney injury.

Intracranial space-occupying lesions, such as tumors or metastases, can be depicted in detail on MRI.

MRI is not necessarily the first choice in acute emergency situations because it is more time-consuming and not immediately available everywhere; usually a cranial CT is performed first.

Consultations

Neurology

Treatment

Acute management of an epileptic seizure in the emergency department

1. Trigger avoidance (e.g., stress, sleep deprivation, alcohol, etc.)

2. For mild to moderate attacks:

• Acetaminophen 500 mg

• Ibuprofen 200 mg

• Naproxen 250 mg

3. For severe attacks:

• Sumatriptan (subcutaneous 4 mg, film-coated tablets 50 mg, nasal spray 20 mg)

• Ergotamine derivatives

(Analgesics should not be used excessively, as this can increase the frequency, intensity, and duration of attacks).

4. Treatment of nausea:

• Ondansetron (Zofran®)

• Tablets (4 mg, 8 mg), orally disintegrating tablets, injectable solution (i.v. or i.m.)

• Metoclopramide (Paspertin®)

Seizure prophylaxis

Patients who suffer from 6 or more headache days per month are considered candidates for prophylactic treatment.

(The absolute number of headache days per month is only one parameter for assessment. Equally important is assessing the impact on the patient’s everyday functioning.)

1. Antiepileptics:

• Convulex (valproic acid)

• Initial dose: 300–600 mg/day

• Target dose: 1000–2000 mg/day

• Dose escalation: gradual titration depending on tolerability and effect

• Side effects: weight gain, tremor, fatigue, nausea, hair loss, liver function disturbances, thrombocytopenia

• Pregnancy: contraindicated due to high teratogenic risk (e.g., neural tube defects, developmental disorders)

• Topamax (topiramate)

• Initial dose: 25 mg once daily

• Target dose: 100–200 mg/day

• Dose escalation: weekly titration (25 mg)

• Side effects: paresthesias, fatigue, weight loss, memory and concentration disturbances, cognitive impairment

• Pregnancy: FDA category D → contraindicated due to teratogenic risk

2. Antidepressants

• Amitriptyline

• Initial dose: 10–25 mg in the evening

• Target dose: 50–150 mg/day

• Dose escalation: slow titration depending on tolerability

• Side effects: fatigue, dry mouth, weight gain, constipation, dizziness, QT interval prolongation

• Pregnancy: use only after strict benefit-risk assessment

3. β-blockers

• Propranolol (Inderal)

• Initial dose: 20 mg orally 2–3× daily

• Dose escalation: weekly titration (20 mg)

• Target dose: 80–160 mg/day, divided into 2–4 single doses

• Indication: Also suitable for patients with arterial hypertension

• Side effects: lethargy (fatigue, lack of drive)

• Contraindications / caution: asthma bronchiale, arterial hypotension

• Timolol

CGRP (calcitonin gene-related peptide) antibodies (monoclonal)

• Erenumab

• Dose: 70–140 mg s.c. once monthly

• Mechanism of action: blockade of the CGRP receptor

• Side effects: constipation, injection site reactions, muscle cramps, rarely hypertension

• Pregnancy: use not recommended due to insufficient data

• Fremanezumab

• Dose: 225 mg s.c. 1× monthly or 675 mg every 3 months

• Mechanism of action: Binding to CGRP ligands

• Side effects: Injection site reactions, fatigue, rare allergic reactions

• Pregnancy: Use not recommended due to insufficient data

• Galcanezumab

• Initial dose: 240 mg s.c. single dose

• Maintenance dose: 120 mg s.c. 1× monthly

• Mechanism of action: Binding to CGRP ligands

• Side effects: Injection site reactions, dizziness, fatigue

• Pregnancy: Use not recommended due to insufficient data

Complications

If headaches persist despite treatment for longer than 72 hours, this is called status migrainosus.

Treatment:

• Sumatriptan (subcutaneous/ nasal)

• Ketorolac (Toradol) 30 mg i.v.

• Prednisone 50–100 mg orally (p.o.) or Dexamethasone 4–8 mg intravenously (i.v.)

• Ondansetron 4–8 mg (for nausea/vomiting)

Migraine can become chronic if it occurs on more than 15 days per month.

Extra

Names:

Ms. Schuster, Konstanz Richter, Lisa Flitz, Wally Geier

Age:

64, 53 and 25 years old

Occupatione:

Photographer, freelance editor

Details:

I always had headaches with my period.

The name and telephone number of the general practitioner.

I was just sweeping the sidewalk in front of my house free of stones and snow with a broom when I suddenly developed a headache.

Pre-existing conditions:

COPD for 4 years
neck tension and shoulder pain for 10 years (her GP, Dr. Koch, explained that these complaints can also cause headaches.)
abdominal pregnancy (unclear what exactly is meant – the patient could not explain it)
myomectomy
ingrown toenail (he had a referral to the surgical outpatient clinic but has not been able to go so far)

Medications:
Acic cream
Lefax chewable tablets as needed

Allergies:

Gluten intolerance
grass pollen allergy

Family history:

Father: brain tumor diagnosed after epileptic seizure
Daughter: suffers from depression, anorexia
Mother suffers from scoliosis

Questions

1. Do I have to stay overnight here? My daughter is at school now and the school will close in an hour.

That depends on the examination results. But if inpatient admission is necessary, we can certainly arrange a solution together with social services or relatives.

2. What do you think if the patient does not go to the GP but comes directly to our clinic?

In that case I consider that a sensible decision, since the complaints were acute and the patient was very worried. With us necessary investigations such as imaging could be initiated immediately to promptly exclude serious causes – for example bleeding or a tumor.

3. Do CT and MRI cause too much radiation exposure?

An MRI does not cause radiation exposure because it uses magnetic fields. A CT, on the other hand, uses X-rays and is associated with some radiation exposure – however, this is generally acceptable when medically justified. A head CT has about 20 times the radiation of a standard X-ray.

4. What is needed for the neurological examination?

• a tuning fork (for vibration sense)

• a reflex hammer (to test deep tendon reflexes)

• a flashlight (for pupil reaction)

• a cotton swab or brush (for touch sensation)

• an ophthalmoscope

5. If an MRI is not available, what would you do?

If the MRI is currently unavailable, the examination can be postponed without problems, as it is not immediately required.

6. What do we say about headaches with shoulder and neck tension?

Tension-type headache

7. Do women or men suffer more often from cephalalgia — and why?

Migraine affects women about three times more often than men. Possible reasons for this are hormonal influences, increased pain sensitivity, and psychosocial factors. Tension-type headaches occur at similar rates in both genders; however, women overall tend to report headaches more frequently.

8. What is the cerebellum and what are its functions?

The cerebellum is a part of the brain located in the posterior skull region beneath the cerebral hemispheres. It is mainly responsible for the coordination of movements, fine-tuning of motor skills, balance and posture. It also plays a role in motor learning – for example when learning movement sequences like writing or cycling. Damage to the cerebellum typically leads to coordination disorders (ataxia), tremor and an unsteady gait.

9. Is there a vaccine against the varicella-zoster virus?

The varicella vaccine (against chickenpox) is recommended in childhood.
(part of the standard vaccination schedule of STIKO in Germany)

The herpes zoster vaccine (against shingles) is recommended for people aged 60 and over (from 50 for certain pre-existing conditions).

10. How did the word migraine originate?

The word migraine goes back to the Greek word “hemikrania,” which means “half skull” (hemi = half, kranion = skull).

11. Could you explain the use of the spray to the patient step by step?

• Shake the spray well.

• Remove the protective cap

• Exhale once deeply.

• Place the mouthpiece against the lips and close them around it.

• Inhale slowly and deeply — and press the spray once while doing so.

• Hold your breath for about 10 seconds.

• Then exhale slowly.

12. What is ‘Laub’?
‘Laub’ denotes the entirety of the leaves of trees and shrubs, especially when they fall in autumn.

13. What is meant by the Lasègue sign?

The Lasègue sign is a clinical test to check for sciatic irritation. The straightened leg of the supine patient is passively raised. If pain occurs along the sciatic nerve, the sign is positive and suggests a lumbosacral nerve root irritation, e.g., with a herniated disc.

14. Questions about COPD

Notes

BMI

Definition and calculation

The Body Mass Index (BMI) is a measure to classify body weight in relation to height. It is calculated by dividing weight in kilograms by the square of height in meters. In the context mentioned, the stated number corresponds to a normal range.

pulsating

Throbbing, like a heartbeat

Regio temporalis

Location: Regio temporalis

The regio temporalis denotes the lateral area of the head at the level of the temple, roughly above the zygomatic bone and in front of the ear. This description indicates localized headaches in the temporal region.

retroorbital

Location: retroorbital

Retroorbital describes a position behind the eyeball within or immediately behind the orbit. The term is used to denote pain or discomfort behind the eye.

Photophobia

Photophobia

Definition: Excessive sensitivity to light that can cause discomfort or pain even under normal or increased light exposure.
photophobia/ light sensitivity

Clinical relevance: Common in ophthalmological problems (e.g., corneal damage) and neurological conditions (e.g., migraine, meningitis) and often leads to eyelid closure or avoidance of light sources.

Phonophobia

Phonophobia

Definition: Hypersensitivity to sounds, in which everyday noises are perceived as particularly disturbing or painful.

Clinical relevance: Can occur in neurological and psychiatric disorders (for example migraine or anxiety disorders) and may lead affected individuals to avoid noisy environments.

Nausea

Nausea

Definition: An unpleasant, often pressing sensation in the upper abdomen or behind the breastbone, which can be accompanied by the urge to vomit.

Emesis

Vomiting

Definition: The active process of emesis, in which gastric contents are forcefully expelled orally from the gastrointestinal tract.

Tachycardia

Tachycardia (palpitations)

Brief description: Increased heart rate that can be subjectively perceived as palpitations. Pathophysiologically it usually arises from increased sympathetic activity or reduced vagal counterregulation.

Causes: Pain can trigger a sympatho-synaptic tachycardia; other common causes are anxiety, fever, hypovolemia, anemia, metabolic disorders, medications or cardiac arrhythmias.

Clinical significance: A short-term, symptomatic increase in pulse is often reactive and self-limiting. However, if additional warning signs such as dizziness, syncope, chest pain or severe dyspnea occur, the likelihood of a relevant cardiac or systemic cause increases.

Paresthesias

Paresthesias (abnormal sensations)

Brief description: Sensory disturbances that can present as tingling, crawling sensations, numbness or burning.

Location and course: They can be localized (e.g., at fingertips) or diffuse and temporary or permanent. In some neurological events paresthesias typically occur before or during the attack.

Possible causes: Causes range from peripheral nerve compression through metabolic disorders to central phenomena such as migraine aura or transient ischemic attack; the exact classification depends on the clinical context.

Aura

Aura

Definition: An aura is a transient, reversible focal neurological symptom that commonly occurs before migraine attacks or less commonly before epileptic seizures.

Characteristics: Auras usually begin gradually and typically consist of visual disturbances (e.g., scintillations, visual field defects), sensory symptoms (tingling, numbness), speech disturbances or other sensory phenomena. The usual duration of a migraine aura is on the order of minutes up to about an hour.

Clinical relevance: The occurrence of an aura can precede the subsequent headache and provides clues to the cause of the attack; the exact manifestation varies individually.

Pyrexia

Pyrexia (fever)

Brief description: Elevated body temperature as a nonspecific sign of systemic or localized inflammation or infection.

Disorders of consciousness, speech disturbances, pareses

Disorders of consciousness, speech disturbances, pareses

Meaning: Sudden impairments of consciousness, loss of speech or motor weaknesses (pareses) are classic warning signs for an acute cerebrovascular event such as ischemic stroke or intracerebral hemorrhage.

Chest pain

Chest pain

Meaning: Pain in the thorax can indicate various acute and potentially life-threatening causes, such as acute coronary syndrome, aortic dissection, pulmonary embolism or a hypertensive emergency with organ involvement. The symptomatology is nonspecific and requires cause-oriented evaluation.

Palpitations

Palpitations (heart pounding)

Meaning: Palpitations describe the subjective sensation of perceivable heartbeats, which can result from tachycardias, arrhythmias, increased adrenergic activity, metabolic disorders or psychological causes. The symptom may require cardiological assessment if it is new, persistent or associated with accompanying symptoms.

Lacrimation

Lacrimation

Meaning: Increased tear flow (lacrimation) can be a result of eye irritation, inflammations, or an autonomic accompanying symptom in trigeminal autonomic cephalalgias such as cluster headache. Especially unilateral, paroxysmal lacrimation suggests a trigeminal-autonomic cause.

Rhinorrhea

Rhinorrhea (runny nose)

Definition: Secretion of increased nasal mucus from the nose, visible as a runny nose or increased nasal discharge.

Clinical significance: Rhinorrhea is a common symptom in infectious or allergic diseases of the upper airways. It can also occur as a unilateral autonomic accompanying symptom in trigeminal autonomic headache syndromes such as cluster headache and be diagnostically relevant.

Hyperhidrosis

Hyperhidrosis (excessive sweating)

Definition: Excessive or increased sweat production that can be localized or generalized.

Clinical significance: Locally limited hyperhidrosis in the face can have various causes, including autonomic dysregulation or as an accompanying autonomic symptom in certain headache disorders (e.g., trigeminal autonomic headache forms). Differential diagnoses also include endocrine, neurological, or medication-induced causes.

similar

New-onset headache in patients over 50 years is striking.

Föhn weather

Föhn wind

Definition: A föhn is a warm, dry downslope wind that forms when air masses descend on the leeward side of a mountain range and is often accompanied by gusty conditions.

Clinical relevance: Weather patterns with rapid changes in temperature and air pressure, as can occur with föhn, are reported by some patients as triggers or amplifiers of headaches. Such relationships are individually variable and not universally valid; however, they should be asked about clinically when patients report weather-dependent complaints.

Insomnia

Insomnia (the sleep disorder)

Insomnia denotes persistent difficulties falling or staying asleep or nonrestorative sleep quality. In this patient it manifests mainly as problems falling asleep, which are exacerbated by recurrent headaches. Additionally, there are occasional sleep interruptions due to nighttime coughing fits related to her known asthma bronchiale.

Asthma bronchiale

Asthma bronchiale

Asthma bronchiale is a chronic inflammatory disease of the airways characterized by recurrent episodes of breathlessness, cough, chest tightness, and wheezing. Contributing factors can include genetic predisposition, allergic sensitizations, infections, environmental factors, or physical exertion. Diagnosis is based on history, physical examination, lung function tests (for example spirometry), and possibly allergy testing. Treatment principles include avoidance of known triggers (in this patient particularly grass pollen during the vegetation period), symptomatic use of bronchodilator medications (short- and long-acting beta-2 agonists), anti-inflammatory therapy with inhaled corticosteroids, and structured education and self-management.

Herpes labialis

Herpes labialis

Herpes labialis is a local infection of the lip region, usually caused by herpes simplex virus type 1. Clinically, a burning or itching sensation often occurs first, followed by fluid-filled blisters that crust over after rupturing. The infection is easily transmissible, for example by direct contact. Reactivations are frequently triggered by stress, sunlight, febrile illnesses, or weakened immunity. Topical or systemic antiviral agents (for example aciclovir) are used for treatment. In this patient, episodes occasionally occur on the lower lip in the context of stress or fever.

Disk prolapse

Disc prolapse

A disc prolapse (herniated disc) occurs when the inner gelatinous core of an intervertebral disc protrudes through the outer fibrous ring and compresses adjacent nerve structures. This can lead to localized neck pain, radiating symptoms, paresthesias, or neurological deficits. Causes include degenerative changes, repetitive mechanical stress, accidents, overweight, and lack of exercise. In this patient there has been a cervical herniation at the level between the fifth and sixth cervical vertebrae for about four years; since then recurrent cervical pain with radiation into the right shoulder has occurred.

Rib contusion

rib contusion
A rib contusion results from blunt force to the chest and affects the ribs and surrounding soft tissues. Typical symptoms are localized pain, tenderness to pressure and occasionally a visible hematoma. In the present case, the injury was on the right after a car accident about five years ago and was treated without surgical intervention. Differential diagnoses to consider include rib fractures or thoracic concomitant injuries, which should be clarified by imaging if necessary.

perforated

perforation (rupture of a hollow organ)
A perforation is an opening through the wall of a hollow organ through which organ contents and microorganisms can enter the body cavity. Clinically this often presents with sudden, severe abdominal pain, guarding, fever and a general deterioration in condition. Common causes are inflammatory conditions such as appendicitis or diverticulitis as well as ulcers. A perforation usually leads to secondary inflammation of the peritoneal cavity and requires timely medical evaluation.

Peritonitis

peritonitis
Peritonitis refers to inflammation of the peritoneum, which can be triggered by bacterial contamination from an organ perforation or by other inflammatory processes. Characteristics are persistent, often diffuse abdominal pain, guarding, fever and a pronounced decline in general condition. In the case described here, the peritonitis occurred as a result of a perforated appendicitis, after which an appendectomy was performed.

Ovarian cyst

ovarian cyst
An ovarian cyst is a fluid-filled cavity on or in the ovary. Many cysts are functional and resolve spontaneously; others are associated with conditions such as endometriosis or polycystic ovary syndrome. Larger or symptomatic cysts can cause lower abdominal pain, a feeling of pressure or menstrual irregularities. Possible complications include cyst rupture, ovarian torsion or bleeding. In this case, a right-sided cyst about ten years ago led to removal of the affected ovary (right oophorectomy).

laparoscopic

Short description:
Laparoscopic refers to a minimally invasive surgical technique in which instruments and a camera are inserted into the abdominal cavity through a few small skin incisions.
Procedure:
With slight elevation of the abdominal wall by insufflation of gas, the surgical field is visualized using a laparoscope and operated on with specially shaped instruments.
Effects and advantages:
This technique avoids a large abdominal incision, preserves tissue, generally leads to less postoperative pain and often allows a shorter recovery time compared with open surgery.

Aciclovir

group:
Aciclovir is an antiviral drug from the group of nucleoside analogues.
mechanism of action:
The agent inhibits replication of herpesviruses by incorporation into viral DNA and disruption of DNA synthesis.
indications:
Aciclovir is used for infections with herpes simplex and varicella-zoster viruses; it is available in various formulations and can be applied topically, systemically or as an ophthalmic ointment.
side effects:
Possible adverse effects include nausea, headache and skin rashes; type and frequency depend on the route of administration.

Salbutamol

mechanism of action and group:
Salbutamol is a beta-2-adrenergic agonist that relaxes the smooth muscle of the bronchi and thereby dilates the airways.
indication:
It is used to treat airway constriction in conditions such as asthma and COPD, usually administered by inhalation.
important notes:
Common side effects are tremor and accelerated heart rate; persistent symptoms should prompt medical advice.

Meteorism

Meteorism

Description: Meteorism denotes visible and palpable abdominal distension due to increased gas accumulation in the gastrointestinal tract. Affected individuals often report bloating, flatulence and visible abdominal swelling.

Causes and note in context: Various mechanisms can trigger it, such as altered gut flora, increased gas production from certain food components or malabsorption. Foods can promote bloating in susceptible individuals; in the present context a connection with consumption of certain nuts is mentioned.

Clinical relevance: Meteorism is a nonspecific symptom that should be interpreted alongside other accompanying symptoms and, if necessary, diagnostic measures.

Erythema

Erythema

Definition: An erythema is a noticeable reddening of the skin caused by increased blood flow in the superficial skin vessels.

Pruritus

Pruritus

Term explanation: Pruritus denotes the subjective sensation of skin itching, which often leads to scratching and can impair skin integrity.

Pack years

Pack years

Definition: A pack year is a unit for quantifying cumulative tobacco exposure over time.

Calculation: To determine pack years, divide the average number of cigarettes smoked daily by 20 (number of cigarettes per standard pack) and multiply the result by the number of years of smoking.

Example in context: For a previous consumption of about 10 cigarettes per day over three years, the value is (10 ÷ 20) × 3 = 1.5 pack years, as stated in the case report.

Female moderator

role and responsibilities
A presenter hosts a program, event or discussion panel, welcomes the audience, introduces topics and guests, guides the course of the discussion and ensures clarity as well as timing.
social history (contextual)
The patient reports working as a presenter at ZDF. She is married, lives with her husband and has no children.

Brain tumor

definition and classification
A brain tumor is a new growth of tissue within the skull that can be benign or malignant; examples include meningiomas (often benign) and glioblastomas (aggressive and malignant).
clinical signs
Symptoms vary with location and size and may include headache, nausea, vomiting, visual disturbances, motor deficits, epileptic seizures or psychological/behavioral changes. Early evaluation is important for therapy and prognosis.
family history
In the family history the patient reports that her father had a brain tumor at the age of 70 and died nine months later.

Total hip arthroplasty

description of the procedure
In a total hip arthroplasty the affected hip joint is completely replaced by an artificial prosthesis to treat painful joint destruction and restore function.
indication (contextual)
A typical reason for such a procedure is advanced osteoarthritis; in the present case the patient’s mother received a right hip THA at age 60 for this reason.

Osteoarthritis

definition and location
Osteoarthritis is a degenerative joint disease; when it affects the hip it is called coxarthrosis. It develops from progressive cartilage wear in the joint.
causes, symptoms and therapy
Causes can include age, overuse, misalignment, overweight or prior injuries. Typical signs are load-dependent pain, limited range of motion and morning stiffness. Treatment ranges from conservative measures (e.g., physiotherapy, weight reduction, analgesic measures) to joint replacement for advanced destruction.
family history (contextual)
The patient’s mother received a right total hip arthroplasty at age 60 due to advanced osteoarthritis.

Ptosis

definition:
Ptosis refers to the drooping of the eyelid, usually the upper lid, which can restrict the visual field.

Miosis

definition:
Miosis describes the reduction of pupil diameter resulting in a smaller-appearing pupil.
context and causes:
It typically occurs with increased parasympathetic activity or due to certain substances and can be a sign of neurological or toxicological processes.

Blood pressure

term and significance:
Blood pressure is the pressure within the arterial vessels and a key vital parameter for assessing circulatory status.
measurement:
Blood pressure is often measured using manual sphygmomanometers, which consist of an inflatable cuff, a inflation bulb (pump) and a manometer; in auscultatory measurement a stethoscope is also used.

Oxygen saturation

definition:
Oxygen saturation indicates the proportion of hemoglobin bound with oxygen relative to total hemoglobin and is a common parameter for assessing oxygenation.
measurement method:
Peripheral oxygen saturation is measured noninvasively with a pulse oximeter that uses photometric measurement on the finger, earlobe or similar sites.

Body temperature

body temperature — measurement sites and conversion
Rectal measurements are considered the reference for core body temperature. Axillary values are typically lower; to estimate central temperature one can roughly add about 0.5 °C to the axillary measurement. Oral measurements are usually about 0.3 to 0.5 °C below the rectal reference value.

Giant cell arteritis

giant cell arteritis
Giant cell arteritis is an inflammatory vascular disease of large and medium-sized arteries, frequently affecting the temporal arteries. It predominantly affects people over 50 years of age. Typical symptoms are unilateral, severe headache and tenderness over the A. temporalis; additionally, visual disturbances and a general malaise may occur. Rapid treatment with glucocorticoids is indicated to prevent serious complications such as permanent blindness.

Touch-

With a cotton swab

Reflexes

reflexes — procedure
Testing deep tendon reflexes is performed with a reflex hammer. The patient should be relaxed, sitting or lying; a targeted strike on the tendons elicits the reflexes, which are assessed for symmetry and degree. Deviations (increased, decreased or pathological reflexes) provide clues to lesions of the peripheral or central nervous system.

Fundoscopy

Fundoscopy

Fundoscopy (ophthalmoscopy) is used for direct assessment of the fundus of the eye. The retina, optic disc (papilla) and retinal vessels are visually examined to detect, for example, hemorrhages, vascular changes or swelling of the optic disc. The examination complements neurological findings when increased intracranial pressure or vascular changes are suspected.

Papilledema

Papilledema

Papilledema is swelling of the optic disc and is a warning sign of increased intracranial pressure. Possible causes include space-occupying lesions, intracranial hemorrhages or impaired cerebrospinal fluid circulation (e.g., hydrocephalus). The presence of papilledema has diagnostic significance for further neurological evaluation and imaging.

Meningismus

Meningismus

Meningismus describes a clinical picture of meningeal irritation. Typical findings are neck stiffness, headache and light sensitivity; nausea and vomiting often occur as well. Meningismus is an important sign in the evaluation of possible meningitis but can also occur in other conditions.

CSF examination

Cerebrospinal fluid examination

Cerebrospinal fluid examination includes obtaining cerebrospinal fluid by lumbar puncture in the lower lumbar spine (e.g., in the L3/L4 or L4/L5 region) under local anesthesia. The patient usually assumes a flexed position. The sample taken is examined chemically and microbiologically (e.g., cell count, protein, glucose, lactate, pathogen diagnostics and, if applicable, cytology). Indications include suspected meningitis, encephalitis, certain inflammatory diseases of the CNS or the detection of hemorrhages in the subarachnoid space.

Valsalva maneuver

Valsalva maneuver

The Valsalva maneuver refers to forced exhalation against a closed upper airway (e.g., straining during defecation or holding one’s breath with strong abdominal pressure). This temporarily increases intrathoracic and venous pressure, which can affect venous return to the heart as well as intracranial pressure. Clinically, the maneuver is known to exacerbate existing headaches or symptoms triggered by increased pressure.

Naproxen

Naproxen

Class and mechanism: Naproxen belongs to the nonsteroidal anti-inflammatory drugs (NSAIDs). It inhibits cyclooxygenase enzymes and thereby reduces the formation of prostaglandin-mediated inflammatory and pain mediators.

Use: Indicated for inflammation-related pain and acute pain episodes.

Important risks and warnings: Common adverse effects affect the gastrointestinal tract (e.g., dyspepsia, ulcers and gastrointestinal bleeding). NSAIDs can also impair renal function and increase cardiovascular risk with prolonged use. Allergic reactions and bronchial hypersensitivity reactions are possible.

Sumatriptan

Sumatriptan

Mechanism and class: Sumatriptan is a serotonin agonist that acts mainly at 5-HT1B/1D receptors, producing vasoconstrictive effects and inhibiting trigeminal pain pathways.

Indication: Primarily for the acute treatment of migraine attacks with or without aura.

Side effects and contraindications: Common side effects include paresthesias, dizziness, sensations of heat and fatigue; pressure or tightness in the chest or throat may occur occasionally. Sumatriptan must not be used in certain cardiovascular diseases or in uncontrolled hypertension; concomitant administration with ergotamines or other triptans is contraindicated. Use during pregnancy should occur only after careful benefit–risk assessment.

Valproic acid

valproic acid — pharmacologic character and use
Valproic acid belongs to the group of anticonvulsants and is also used as a mood-stabilizing agent. Pharmacologically it is antiepileptic and influences neuronal excitability.
common side effects
Regularly observed adverse effects include gastrointestinal complaints, weight gain, tremor and reversible hair loss.
important risks and contraindications
Serious risks include hepatotoxic damage and pancreatitis. Valproic acid is contraindicated in pregnancy due to a high teratogenic risk.

Amitriptyline

amitriptyline — drug class and indications
Amitriptyline belongs to the tricyclic antidepressants (TCAs) and is used not only to treat depressive disorders but also for chronic pain syndromes and migraine prophylaxis.
typical side effects
Common adverse effects are dry mouth, pronounced drowsiness, constipation, weight gain and orthostatic drops in blood pressure. Many effects are due to anticholinergic and sedative properties.
Major risks
In pre-existing cardiovascular disease, special risks for cardiac side effects must be considered.

Vulture

Vultures — Description and lifestyle
Vultures are large birds of prey that primarily feed on carrion. They are characterized by a robust body build and adaptations to scavenging.
Ecological role and distribution
As scavengers, vultures play an important role in the ecosystem by disposing of carcasses. Different species are distributed in various regions of the world.

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