What is the best course of treatment for a 37-year-old male patient with headaches, history of stroke, and mild flat feet (pes planus), who has fluid in the left side of his head and a scar on the left parietal from a previous surgery?

Management of a 37-Year-Old Male with Post-Stroke Headaches and Flat Feet

For this patient with post-stroke headaches, history of intracranial fluid, and mild flat feet, the most appropriate treatment plan includes antiplatelet therapy (aspirin 75-325 mg daily), statin therapy to reduce LDL to <70 mg/dL, acetaminophen for headache management, and over-the-counter arch supports for mild flat feet.

Stroke Management

Antiplatelet Therapy

• Initiate aspirin 75-325 mg daily as first-line antiplatelet therapy for secondary stroke prevention 1
• Alternative options if aspirin is contraindicated:
  • Clopidogrel 75 mg daily
  • Combination of aspirin plus extended-release dipyridamole (25 and 200 mg twice daily)

Lipid Management

• Start statin therapy to reduce LDL-cholesterol to a level near or below 70 mg/dL 1
• Consider high-potency statin (atorvastatin 40-80 mg or rosuvastatin 20-40 mg)
• Monitor lipid levels at 4-12 weeks after initiation

Additional Vascular Risk Factor Management

• Blood pressure control (target <140/90 mmHg)
• Smoking cessation if applicable
• Diet and exercise counseling
• Diabetes management if applicable

Headache Management

Acute Treatment

• Acetaminophen 325 mg, 2 tablets TID PRN is appropriate for acute headache management
• Avoid overuse of analgesics (limit to <15 days/month) to prevent medication overuse headache

Evaluation for Post-Stroke Headache

• Obtain complete neuroimaging records from Twin Falls to assess:
  • Nature of "fluid inside the left side of his head"
  • Relationship between prior surgery (25 years ago) and current symptoms
  • Extent and location of previous stroke

Red Flags Requiring Urgent Attention

• Worsening headache pattern
• New focal neurological deficits
• Headaches that wake patient from sleep
• Signs of increased intracranial pressure

Management of Flat Feet (Pes Planus)

Assessment

• Patient has mild flat feet that do not meet criteria for custom orthotics
• Mild flat feet without significant symptoms generally do not require aggressive intervention

Treatment

• Over-the-counter insoles (size 10.0) are appropriate for mild, asymptomatic flat feet 2
• Arch supports would have been beneficial but were declined by patient

Follow-Up Plan

1. Obtain and review medical records from Twin Falls
2. Schedule follow-up appointment after records review to:
   • Reassess headache pattern and response to acetaminophen
   • Evaluate need for prophylactic headache treatment if headaches persist
   • Initiate appropriate vascular risk reduction therapy based on complete history
   • Consider neurology referral if headaches persist or worsen

Pitfalls to Avoid

• Avoid triptan medications in patients with history of stroke 1
• Do not prescribe custom orthotics for mild, asymptomatic flat feet as evidence does not support their use in this context 2
• Avoid NSAIDs as first-line treatment for headache in patients with stroke history due to potential bleeding risk
• Do not delay obtaining complete medical records as understanding the nature of the "fluid inside the left side of head" is critical for appropriate management