Presented by Ayse Avcioglu, MD
CC: “I have a headache”.
HPI: Patient is a 33 year old female who presents to the ED complaining of 8/10 bifrontal headache described as a steady dull ache. She has had the headache for over a year on and off but for the last two days it has progressively become worse. Tylenol makes the pain slightly better, but the pain seems to be more severe early on in the morning on awakening. She denies any vomiting. She also has been having trouble driving as she sometimes has difficulty seeing out from the side mirrors. She has been healthy otherwise except for the inability to conceive as she and her husband have been trying to get pregnant for the past year. There has also been some white discharge from both breasts. Otherwise, she denies any fever, neck pain, or any motor weakness.
ROS: all negative except per HPI.
SH: denies tobacco or illicit drug use. Occasional alcohol use.
LMP: irregular, cannot recall last date.
Vital signs: BP: 132/78 P: 107 R: 20 T: 36.8
General: Pleasant appearing female in no acute distress.
HEENT: Head is NC/AT. Pupils 3 mm bilaterally, equal and reactive to light and accommodation. EOMI no nystagmus noted. Fundus: clear disc margins, venous pulsations present, no hemorrhages or disc hyperemia.
Heart: Normal S1/S2. No murmurs, rubs, gallops.
Lungs: Clear bilaterally.
Breast: no discharge visualized.
Abdomen: Soft, nontender, nondistended. + bowel sounds. No organomegaly.
Musculoskeletal: Normal AROM. Normal muscular bulk and tone.
Skin: no rashes or striae.
Neurological: Alert, oriented x 3. Speech clear. Diminished peripheral visual fields on confrontation. CN III-XII intact. + 2 biceps/triceps/knee/achilles equal and symmetrical. No Babinski. Sensation: light touch, pain, vibration normal and symmetrical. Motor: proximal/distal muscle strength 5/5 equal and symmetric. Coordination/gait: no extended arm drift, finger to nose/heel to shin intact and symmetric. Rapid alternating hand and finger movements intact. Rhomberg negative. Gait normal, able to walk on toes and heels.
1. Based on the case scenario and the image below, the most likely diagnosis is:
2. On one busy ER shift you are called to resuscitation bay for a medical code. EMS brings a 35 year old male with complaints of sudden severe headache described as retro-orbital with associated vomiting, generalized weakness, and diplopia . Vital signs: BP: 80/52, P: 122 , RR: 16, T: 36.8.
The images below correspond to the next two questions.
What is the most likely cause of this patients clinical presentation?
a. bacterial meningitis
b. subarachnoid hemorrhage
c. cerebral vascular accident (CVA)
d. pituitary apoplexy
e. CNS tumor
3. What should be the initial step in management for this patient?
a. call neurosurgery for STAT decompression
b. administer 4 units FFP
c. lumbar puncture
d. give 100 mg hydrocortisone IV
e. check coagulation panel
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