Sudden Headache and Vomiting in a 33-Year-Old Woman

Roshen Mathew, MBBS; Mathew Abraham, MD, DM


September 12, 2016

Physical Examination and Workup

Upon physical examination, the patient appears well nourished but mildly dehydrated. She is tearful and states that the intensity of her headache is currently 7 on a scale of 1-10 (with 1 being no pain and 10 being the highest intensity). She is alert and oriented to her surroundings. Her vitals show a temperature of 98.7°F(37.1°C), a blood pressure of 140/90 mm Hg, and a heart rate of 90 beats/min.

Figure 1.

Examination of the head and neck is normal, with good range of motion, no focal tenderness to palpation, and no meningeal signs. The pupils show a slightly sluggish reaction bilaterally to light. The patient's lungs are clear to auscultation, with normal breath sounds. She has normal S1 and S2 heart sounds. No murmurs or clicks are heard on auscultation. She has a soft and nontender abdomen.

Upon neurologic examination, the patient's mental status is normal. The cranial nerves are normal, except for bilateral papilledema noted on funduscopic examination. In the extremities, motor strength is rated at 4 of 5 in the left lower extremity and 5 of 5 in the right lower and bilateral upper extremities (on a scale of 1-5, with 5 being normal strength). Deep tendon reflexes are difficult to elicit, but they are symmetric bilaterally, with normal plantar reflexes. Her sensation is intact bilaterally to pain, touch, and vibration. Finger-to-nose testing does not show past pointing, and her gait is not ataxic.

Laboratory investigations, including a complete blood cell count, erythrocyte sedimentation rate, and basic metabolic profile, are all within normal limits. A urine pregnancy test is negative. CT and MRI of the brain are normal. A magnetic resonance venogram (MRV) is obtained (Figure 1).


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