CC: “I have a bad headache”

HPI

17 y/o female with no PMH presenting to the ED accompanied by her mother, with worsening headache on and off x8 days.  Patient states the headaches are left-sided, from front to back, rated a8/10, and does not radiate. She states the headaches begin when she wakes up in the morning and worsens in the afternoon. She has taken Advil and Tylenol which did not provide relief, although she did not specify the dosage of each medication.  The headaches have been occurring intermittently every other day, but got worse today around 11am while at work and is now accompanied by slightly blurry vision, drooping of the left upper eyelid and tearing of the left eye. Denies history of trauma, nausea, vomiting, photophobia, neck pain, neck stiffness, back pain, dizziness, fatigue, extremity weakness, hearing loss, speech impairment, loss of balance, seizures, vertigo, history of cluster headaches, migraines, tension headaches. Denies any recent travel, sick contacts, fever, cough, chest pain, or shortness of breath,  

  

PMH/PSH

No pertinent past medical history.

No pertinent surgical history.

Immunizations: Up to date with immunizations.

 

Family History 

Mother: Type 2 diabetes, alive 

Father: Hypertension, alive

Social History

Highschool senior, works as a cashier at a supermarket on weekends. 

Non smoker, never smoked. No alcohol or illicit drug use.

Medications:

Acetaminophen 325 mg 2 tablets PO q6 hr PRN

 

Review of Systems

Constitutional: Negative for change in weight, fever, chills, fatigue.

Head: See hpi.

ENT: Negative for congestion, ear pain, hearing loss, sinus pressure and sore throat. 

Eyes: Positive for blurred vision and visual disturbance. Negative for photophobia, pain, discharge, redness and itching.

Respiratory: Negative for cough or SOB

Cardiovascular: Negative for chest pain, palpitations, irregular heart rhythm, syncope and near-syncope.

Gastrointestinal: Negative for abdominal pain, diarrhea, consolation, nausea and vomiting.

Musculoskeletal: Negative for back pain, myalgias, neck pain and neck stiffness.

Skin: Negative for rash.

Neurological: See hpi

 

Physical Exam

Vitals: BP: 120/72, P 90, RR 18, O2 99% room air, Temp 97.6 F, BMI 27.54 kg/m²

LMP 12/20/20

General: She is not in acute distress, not ill-appearing. She is well-developed.

Head: Normocephalic and atraumatic. 

Eyes: Slight left ptosis with tearing. Extraocular movements intact. Right eye: Normal extraocular motion and no nystagmus. Left eye: Normal extraocular motion and no nystagmus. Pupils are equal, round, and reactive to light. 

Ears: TMs is pearly grey with no budging. No discharge or drainage is noted in the external canals.

Nose: Nasal mucosa is moist. No purulent discharge or blood.

Mouth and throat: Oral mucosa is moist, without lesions. Gums appear healthy.

Neck: No swelling or tenderness. No cervical adenopathy.

Cardiovascular: S1, S2. Normal rate and regular rhythm.

Pulmonary: Clear to auscultation bilaterally. No wheezes, rales, rhonchi.

Abdomen: Bowel sounds are present. Nontender, nondistended.

Musculoskeletal: Normal range of motion in upper and lower extremities. No extremity edema.

Skin: Skin is warm. Capillary refill takes less than 2 seconds.

Neurological: Mental Status: She is alert and oriented to person, place, and time. GCS 15. Cranial Nerves: CN II-X11 intact. No sensory deficit. No weakness. Gait normal.

Psychiatric: Speech and behavior normal.   

 

Labs

BMP within normal limits 

135|101|14 < 95

3.8|25|0.77

 

Hepatic Function Panel within normal limits 

Albumin 4.9

Total Protein 8.1

Total Bilirubin 0.3

Direct Bilirubin <0.2

ALK PHOS 46

ALT 22

AST 26

 

CBC within normal limits

4.82>12.6<251

          40.5

 

CT head no contrast:

FINDINGS:

Brain: No hemorrhage. No significant white matter disease. No edema.

Cerebral ventricles: No ventriculomegaly.

Bones/joints:  No acute fracture.

Paranasal sinuses: Visualized sinuses are unremarkable. No fluid levels.

Mastoid air cells: Unremarkable as visualized. No mastoid effusion.

Soft tissues: Unremarkable. 

 

CTA head without contrast 

IMPRESSION:

No carotid or vertebral artery stenosis or dissection.

 

MRI brain with/without contrast 

1. Partially empty sella, of uncertain clinical significance. Otherwise, unremarkable noncontrast and gadolinium enhanced MRI examination of the brain. No focal mass lesions, collections or other significant parenchymal abnormalities are appreciated. The diffusion sequences also fail to demonstrate any acute, subacute or territorial infarcts.

2. No intra or extraconal focal mass lesions or collections are seen on the MRI examination of the orbits. No enhancing lesions are identified in the parasellar/cavernous sinus lesions or surrounding structures as well.

IMPRESSION:

No acute intracranial abnormality.

 

Assessment:

17 y/o female with no PMH presenting to the ED with worsening headache on and off x8 days likely secondary to cluster headache.

Plan:

• Likely cluster headache: IV fluids, ibuprofen 
• Not likely subarachnoid hemorrhage, cervical neck dissection. CTA head and neck and CT head negative. 
• MRI showed optic nerve head w/o edema or pallor – headache not likely due to ophthalmologic condition 
• F/u on acetylcholine receptor AB and Anti-MuSK AB r/o MG
• F/u with neuro and ophthalmology 
• If patient’s symptoms improve tomorrow and imaging studies all negative, can be clear for discharge with input from ophthalmology. 
• If any changes in vision, recurrent diplopia, patient advised to return to ED for further evaluation