Part 3 

A 45-year-old Hispanic female, Ms. Rodriguez, presents to the clinic complaining of sudden onset headache. She states this headache is different from her previous migraine headaches. The headache pain is described as a 10 on a scale of 0-10 with 10 being the worst pain. The pain is nonradiating, and she has mild photophobia. She did not get relief with sumatriptan (Imitrex), which previously provided relief for her migraines. She feels nauseous and states she vomited twice.

Physical examination findings are as follows:

 

• • Vital signs: temperature 98.8°F; pulse 88 beats per minute; respirations 20 per minute; blood pressure 150/95 mmHg; pulse oximeter 100% on room air.
  • General appearance: alert, in mild discomfort due to pain.
    Head, Eyes, Ears, Nose, and Throat: normocephalic, atraumatic; pupils equal, round, reactive to light and accommodation; sclera nonicteric; extraocular movements intact; no nystagmus; optic disc margins are sharp with no evidence of papilledema or hemorrhaging noted.
  • Lungs: clear to auscultation bilaterally.
  • Cardiac: regular rate and rhythm; S1, S2 with no murmur.
  • Abdomen: soft, depressible, nontender, no organomegaly.
  • Neuro: cranial nerves II-XII intact; muscle strength 5/5; deep tendon reflexes 2+ and symmetrical throughout; no pronator drift; negative Romberg sign; coordination intact; gait steady.

QUESTIONS

1. What is your differential diagnosis?
2. What are your risk factors for meningitis? Subarachnoid hemorrhage (SAH)?
3. What imaging would you like to do?
4. Discuss the difference between a headache that presents gradually as compared to a headache that presents suddenly.
5. What other history to you want to obtain from this patient?
6. What clinical findings would you anticipate with meningitis?
7. What clinical findings would you anticipate with SAH