jmj11 Posted December 31, 2014 Share Posted December 31, 2014 Don't see many cases that are "ER-interesting" in the headache clinic but here is one. My "riddles" are a quick and cheap case presentations. I will give some hints. You are allowed to ask yes or no questions and I will answer them truthfully and see who is the first one to figure this out. Christmas Eve I saw a 33 yo female with a long history of migraine but not too severe and a few times a month. In the past six weeks headaches became worse and finally daily. No other major complaints except for typical migraine (photo phobia, nausea). I was ready to call this typical status migraine until I examined her. She had two positive signs, one neurological and one not. After my exam I had a differential of two things. I guessed the more common one . . . however it turned out to be the other. I wish I had sent her directly to the ER but I started the work up for # 1 first. She ended up in the ER in 48 hours. It is NOT an infectious process. So, each person is allowed two Y/N questions and then a guess. The winner gets all the oxygen they can breath for free for one year. Link to comment Share on other sites More sharing options...
MedicinePower Posted December 31, 2014 Share Posted December 31, 2014 1) Were her headaches position in nature? (Better when horizontal, worse when vertical?) 2) Was there any discharge/runniness from her nose or weird metallic taste in her mouth? Link to comment Share on other sites More sharing options...
primadonna22274 Posted December 31, 2014 Share Posted December 31, 2014 Interesting. I'll play. 1. Was there anisocoria? 2. EOMI? Any proptosis or lid lag? Dysconjugate gaze? Nystagmus? 3. Equal upper extremity pulses? 4. Any unusual pigmentation patterns on irises, face, palate, scalp that may make you think of brain/spinal cord developmental anomalies? Link to comment Share on other sites More sharing options...
Guest Paula Posted December 31, 2014 Share Posted December 31, 2014 Did she have diplopia or urinary symptoms or ataxia? Link to comment Share on other sites More sharing options...
jmj11 Posted December 31, 2014 Author Share Posted December 31, 2014 1) Were her headaches position in nature? (Better when horizontal, worse when vertical?) 2) Was there any discharge/runniness from her nose or weird metallic taste in her mouth? 1) No 2) No Link to comment Share on other sites More sharing options...
jmj11 Posted December 31, 2014 Author Share Posted December 31, 2014 Interesting. I'll play. 1. Was there anisocoria? 2. EOMI? Any proptosis or lid lag? Dysconjugate gaze? Nystagmus? 3. Equal upper extremity pulses? 4. Any unusual pigmentation patterns on irises, face, palate, scalp that may make you think of brain/spinal cord developmental anomalies? Okay, two questions at a time. 1) No 2) Part 1: No Link to comment Share on other sites More sharing options...
jmj11 Posted December 31, 2014 Author Share Posted December 31, 2014 Did she have diplopia or urinary symptoms or ataxia? Question 1: No, Question 2: No . . . 3: GAME VIOLATION :>0, Two questions at a time. Link to comment Share on other sites More sharing options...
primadonna22274 Posted December 31, 2014 Share Posted December 31, 2014 Interesting. So EOMs not intact. Where was the defect? Lateral gaze, medial, upward or downward? And which eye? (Or was it a bilateral deficit?) Link to comment Share on other sites More sharing options...
jmj11 Posted December 31, 2014 Author Share Posted December 31, 2014 Interesting. So EOMs not intact. Where was the defect? Lateral gaze, medial, upward or downward? And which eye? (Or was it a bilateral deficit?) I'm sorry, I meant a double negative . . . no they are not not intact . . . in other words the EOMs were perfect. Link to comment Share on other sites More sharing options...
jmj11 Posted December 31, 2014 Author Share Posted December 31, 2014 Okay . . . second quarter reset. New hint. The ultimate culprit (or at least it appears at this point) for the signs and symptoms does not reside in the head. Everyone gets two more questions. Link to comment Share on other sites More sharing options...
gbrothers98 Posted December 31, 2014 Share Posted December 31, 2014 Is the culprit in her neck or in her heart? Link to comment Share on other sites More sharing options...
MedicinePower Posted December 31, 2014 Share Posted December 31, 2014 Kidney involvement? Link to comment Share on other sites More sharing options...
jmj11 Posted December 31, 2014 Author Share Posted December 31, 2014 Is the culprit in her neck or in her heart? 1) No and 2) No Link to comment Share on other sites More sharing options...
jmj11 Posted December 31, 2014 Author Share Posted December 31, 2014 Kidney involvement? 1) Yes Link to comment Share on other sites More sharing options...
jdenning Posted December 31, 2014 Share Posted December 31, 2014 Can we assume she is REALLY hypertensive??? Link to comment Share on other sites More sharing options...
jmj11 Posted December 31, 2014 Author Share Posted December 31, 2014 Can we assume she is REALLY hypertensive??? Yes, that was positive sign # 1. Couldn't get her B/P. Kept pumping up and pumping up. Finally got it at 220/160 to which I said, "Holy Crap!" She didn't look ill and responded that she has had episodic elevated blood pressures for a while, when she is in pain. To which I said, "But not to this level?" She affirmed that it does go that high and her PCP was aware of that. But when she was not in pain (and her pain was only about a 7/10 when I took her B/P) her B/P is normal. I should have sent her to the ER but . . . it was the last patient of Christmas Eve, she was confident that her PCP wasn't alarmed at it. I started her on Nadolol at 40 MG with a plan to raise it to 80 by the next morning if her B/P was not back near normal. I had her check her B/P every 4 hours. But I will pause at this point until the other sign is figured out and the rest of the story is disclosed. Link to comment Share on other sites More sharing options...
jdenning Posted December 31, 2014 Share Posted December 31, 2014 Did she have tremor? especially a new onset tremor - probably bilateral. If yes, then I'm going to make a guess.... Link to comment Share on other sites More sharing options...
jmj11 Posted December 31, 2014 Author Share Posted December 31, 2014 Did she have tremor? especially a new onset tremor - probably bilateral. If yes, then I'm going to make a guess.... No . . . sorry. Link to comment Share on other sites More sharing options...
jdenning Posted December 31, 2014 Share Posted December 31, 2014 well, it would be weird to actually ever see a pheo in practice. Papilledema? Link to comment Share on other sites More sharing options...
jmj11 Posted December 31, 2014 Author Share Posted December 31, 2014 well, it would be weird to actually ever see a pheo in practice. Papilledema? Yes . . . the second positive sign. She actually had severe papllidema, the worst I've ever seen and I've seen several. So, I found her l papilledema after I found her hypertension and became quite fixated on that. I considered pseudotumor first, with an incidental significant hypertension. I set her up for a ophthalmology exam + brain MRI on Dec 26th. We called to get the results and they reported that she never showed up. It took some effort to follow her trail but I found out that she had been seen at a local ER 48 hours after I saw her with an admitting complaint of "worsening headache, nausea and vomiting of migraine." I got their notes from the ER. There were some strange things about the notes I have a sense that they were accidentally default "normal" as they listed her exam (including eye) as normal, and her vitals as B/P 140/80. But then the Impression was "Severe hypertension crisis probably related to acute renal failure." She was transferred to a Seattle hospital where they could do an emergent renal bx. Her CT brain was normal. So, based on that information and I don't have any other, it appears that her dx is hypertensive emergency with papllidema caused by acute renal failure. But that is still a working dx. If I ever find out the end of this story I will let you know. I wish I had sent her to the ER the day I saw her but she didn't appear symptomatically ill and I've worked up many pseudotumor patients in that order: Ophthalmologist, brain MRI/V, LP with opening pressures. Link to comment Share on other sites More sharing options...
MedicinePower Posted December 31, 2014 Share Posted December 31, 2014 At any point did she mention something along the lines of, "I haven't urinated in a week"? I suspect her K+ is pretty high and she's at risk of cardiac involvment. I hope the ER did a CMP and 12 lead. Link to comment Share on other sites More sharing options...
jmj11 Posted December 31, 2014 Author Share Posted December 31, 2014 At any point did she mention something along the lines of, "I haven't urinated in a week"? I suspect her K+ is pretty high and she's at risk of cardiac involvment. I hope the ER did a CMP and 12 lead. She never reported to me any urinary symptoms during our ROS. I'm looking at her ER note and she didn't report to them any urinary symptoms. In the ER her Creatinine is was 13.3 MG/DL and her BUN 102.0 MG/DL. Urine Protein >300 MG/DL. Her other labs were normal. In my 35 years of working in headache I never saw worsening headache as the presenting symptom of acute renal failure with related hypertensive emergency (and papilledema ). I've seen many pseudotumor with papilledema. I was listening for horses when it was a zebra. I tried to take a photo of her fundi with my Iphone adapter but it is not clear. However, this (not her fundi) is close to what I saw: Link to comment Share on other sites More sharing options...
gbrothers98 Posted December 31, 2014 Share Posted December 31, 2014 Great case. You are right, in retrospect with a diastolic that high, she should have been sent to the ED that night. If she refused, clear documentation that you told her she had/has high likelihood for significant morbidity and potential mortality. GB PA-C Link to comment Share on other sites More sharing options...
jmj11 Posted December 31, 2014 Author Share Posted December 31, 2014 Great case. You are right, in retrospect with a diastolic that high, she should have been sent to the ED that night. If she refused, clear documentation that you told her she had/has high likelihood for significant morbidity and potential mortality. GB PA-C I agree. This is no excuse but I did fail to mention that she had been in the ER with the same complaints twice in the previous two weeks, both times treated as acute migrine. She had elevated B/P during those visits but no labs were done. They did not see her papilledema. I mean it is possible that she developed papilledema just before coming into our door . . . but I doubt it. Link to comment Share on other sites More sharing options...
Guest Paula Posted December 31, 2014 Share Posted December 31, 2014 jmj: good case. I will admit I am not very good at fundoscopic exams. I'm betting at the ER it wasn't done. I will take this case to heart and work at doing better fundoscopic exams. I honestly don't know why I find them hard to do....I also have had difficulty looking at things under a microscope. Too much stuff floating around, but it could be my eyes and the posterior vitreous detachments that I get...IDK. Does anyone have any tips? Link to comment Share on other sites More sharing options...
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