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Case Summary

A 23-year-old female with no significant medical history presented to the ED with a severe headache, described as the worst headache of her life. The headache came on suddenly three hours earlier while sitting, involved her entire head, and was rated at a level of 10 (on a scale of 0 to 10). She reported associated nausea, vomiting and sensitivity to light, but denied neck stiffness, fevers or chills, visual changes, focal weakness, numbness or trauma. She had not experienced such headaches in the past and denied illicit drug use. Her only medication was oral contraceptives. Her last normal period was two weeks earlier.

PHYSICAL EXAMINATION

GENERAL APPEARANCE: The patient appeared well nourished, well hydrated, lethargic and in acute discomfort.

VITAL SIGNS
Temperature: 97.9
Pulse: 94 beats/minute
Blood pressure: 118/69 mmHg
Respirations: 18 breaths/minute
Oxygen saturation: 100% on room air

HEENT: PERRL, EOMI, no nystagmus, moderate photo-phobia

NECK: Supple, no meningeal signs.

CARDIOVASCULAR: Regular rate and rhythm without rubs, murmurs or gallops.

LUNGS: Clear to auscultation bilaterally.

ABDOMEN: Soft, nontender, nondistended.

EXTREMITIES: No clubbing, cyanosis or edema.

NEUROLOGIC: Somnolent but easily arousable, oriented to person, place and time. Cranial nerves II-XII grossly intact; upper and lower extremity strength 5/5 bilaterally, proximal and distal. Sensation grossly intact, no pronator drift, no dysmetria on finger-to-nose testing.

A peripheral intravenous line was placed, blood was sent for laboratory testing, and a noncontrast CT of the brain was obtained. The patient was given morphine sulfate and Zofran IV for pain and nausea, respectively. Laboratory tests, including a complete blood count, electrolytes, creatinine, glucose and coagulation studies, were within normal limits. A serum pregnancy test was negative.

Differential Diagnosis (DDx) & Management

Additional Cases

Case 1: 26-year-old male with neck pain

HISTORY OF PRESENT ILLNESS
26-year-old male who felt a “pop” in his lower neck while practicing his golf swing. Physical examination revealed midline tenderness to palpation.

VITAL SIGNS
Temperature: 98.1 f / 36.7C
Pulse: 80 beats/minute
Blood pressure: 126/88 mmHg
Respirations: 22 breaths/minute
Oxygen saturation: 100% on room air

Next Steps: What is your DDx? And recommended course of treatment or referral?

Case 2: 42-year-old male with chest pain

HISTORY OF PRESENT ILLNESS
42-year-old male with history of chest pain.

VITAL SIGNS
Temperature: 97.6◦F (36.4◦C)
Pulse: 56 beats/minute
Blood pressure: 142/74 mmHg
Respirations: 22 breaths/minute
Oxygen saturation: 97% on room air

Next Steps: What is your DDx?

Case 3: 76-year-old female with syncope

HISTORY OF PRESENT ILLNESS
76-year-old female presents after fainting while shopping. Denied any head trauma.

VITAL SIGNS
Temperature: 98◦F (36.6◦C)
Pulse: 54 beats/minute
Blood pressure: 138/53 mmHg
Respirations: 22 breaths/minute
Oxygen saturation: 98% on room air

Next Steps: What is your DDX?

Images of Other Cases