A Retired Teacher With a Constant Headache and Vomiting

Amanda L. Blackmon, DO, MS; Lauren Pinter-Brown, MD


January 05, 2022

Physical Examination and Workup

Upon physical examination, the patient is afebrile and hemodynamically stable. He is a well-appearing elderly man in mild distress. He is normocephalic and atraumatic. His mucous membranes are moist, and no tonsillar enlargement is noted. His pupils are equal and round and reactive to light and accommodation. His extraocular movements are intact. Neurologic examination reveals no focal deficit. His motor strength is 5/5 in bilateral upper and lower extremities. He has no lymphadenopathy or hepatosplenomegaly.

Laboratory studies are unrevealing and include the following:

  • White blood cell count: 6,100 cells/µL (75% neutrophils); reference range, 4,000-11,000 cells/µL (55% to 70% neutrophils)

  • Hemoglobin B level: 13.4 g/dL (reference range, 13.5-17.5 g/dL)

  • Platelet count: 163,000 cells/µL (reference range, 150,000-450,000 cells/µL)

  • Sodium level: 136 mmol/L (reference range, 135-145 mmol/L)

  • Potassium level: 3.7 mmol/L (reference range, 3.6-5.2 mmol/L)

  • Chloride level: 107 mmol/L (reference range, 96-106 mmol/L)

  • Bicarbonate level: 26 mmol/L (reference range, 23-30 mmol/L)

  • Blood urea nitrogen level: 23 mg/dL (reference range, 6-24 mg/dL)

  • Creatinine level: 0.9 mg/dL (reference range, 0.6-1.2 mg/dL)

  • Glucose level: 85 mg/dL (reference range, <140 mg/dL)

  • Alkaline phosphatase level: 57 IU/L (reference range, 44-147 IU/L)

  • Alanine aminotransferase level: 11 U/L (reference range, 4-36 IU/L)

  • Aspartate aminotransferase level: 12 U/L (reference range, 8-33 U/L)

  • Total bilirubin level: 0.8 mg/dL (reference range, 0.1-1.2 mg/dL)

  • Albumin level: 4.2 g/dL (reference range, 3.5-5.5 g/dL)

  • Total protein level: 6.7 g/dL (reference range, 6-8.3 g/dL)

  • Thyroid-stimulating hormone level: 1.18 mU/L (reference range, 0.45-4.5 mU/L)

  • International normalized ratio: 0.97 (reference range, <1.1)

  • Partial thromboplastin time: 24.3 s (reference range, 60-70 s)

  • Lactate dehydrogenase (LDH) level: 235 U/L (reference range, 140-280 U/L)

MRI of the brain reveals mild to moderate hydrocephalus (Figure 1).

Figure 1.

A high-volume lumbar puncture is performed. Opening pressure was 27 cm H2O. Cerebrospinal fluid (CSF) analysis reveals 338 nucleated cells, 38% lymphocytes, 51% others, 11 red blood cells, a protein level of 1530 mg/dL, and a glucose level of 20 mg/dL. The patient's headache improved after the high-volume lumbar puncture.


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