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November Case

 
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November Case - November 12, 2008 11:12:50 PM   
Dr.Wagner


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A 45 year old female presents complaining of unilateral visual deficits (photopsia and blind spots lasting 30 minutes) which have ceased, followed by profound headache for 4 hours.  She has vomited twice and has had facial parasthesia. 
Family members are very concerned and she appears ill and prefers the room dark.
Medications: Amoxil, vistiril, and atrovent nasal spray

What would you like to proceed with...

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RE: November Case - November 12, 2008 11:56:01 PM   
Sebastian Asselbergs

 

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Welcome back, Wags.
photopsia and severe headache could be migraine - add vomiting and facial paraesthesia and fotosensitivity (dark room) and I am thinking still migraine, but also intracranial near the occipital lobe - infarction?
So, head imaging.

And find out why antibiotic was prescribed - and isn't vistiril an anti-histamine/sedative? Why did she get that?
I do not know the interaction of these two....

< Message edited by Sebastian Asselbergs -- November 13, 2008 12:00:04 AM >


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RE: November Case - November 13, 2008 12:10:23 AM   
bonez

 

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Glad to see you back Wags. Well we need to think of the serious conditions and work back here. The head imaging is a good idea but we have to keep disections(vertebral, int carotid as well) so vascular imaging also.

Was the headache unique? How about the quick neuro screen was there ataxia , aphasia dysphonia and equilibrial issues?

Those taken care of then a blood work up for completeness

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RE: November Case - November 13, 2008 3:13:46 AM   
jma

 

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Migraine going on? Has her eyes been checked by an opthalmologist? Increased eye pressure. Any drug to drug interaction going on here as well?

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RE: November Case - November 13, 2008 6:29:29 AM   
steve

 

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Possible thunderclap headache? Agree with investigation for vertebral and internal carotid arteries along with head imaging. Would laso like to know why she is on the antibiotic and any pertinent medical history.

I like Couture this weekend, how bout you Wags?

Steve

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RE: November Case - November 13, 2008 5:48:32 PM   
Dnorwood

 

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I would agree with head imaging (fMRI maybe?) and as to what she is taking the antibiotic for.  Would also wonder why she is doubling up on allergy medications.  Could be a migraine, is the facial parasthesia unilateral?  Could taking the atrovent ontop of the vistiril be causing a reaction?  I don't know the interaction between the two.

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RE: November Case - November 13, 2008 11:38:31 PM   
Dr.Wagner


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Pt reports antibiotic was initiated due to recent diagnosis of sinusitis...

Non contrasted Head CT was ordered and was "negative"

Parasthesia generalized and bilateral with lip numbness.

Any other testing?

Is this adequate to rule out a SAH?  Is SAH part of the differential?
Could the vistiril be a clue to the diagnosis?


Thoughts?


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RE: November Case - November 14, 2008 1:03:59 AM   
Dnorwood

 

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I she taking the medications as directed?  Is she abusing the vistiril or the atrovent thus causing an interaction between the two?  Forgive my ignorance, but what is SAH in reference to?

< Message edited by Dnorwood -- November 14, 2008 1:22:41 AM >


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RE: November Case - November 14, 2008 2:34:57 AM   
bonez

 

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quote:

ORIGINAL: Dr.Wagner

Pt reports antibiotic was initiated due to recent diagnosis of sinusitis...

Non contrasted Head CT was ordered and was "negative"

Parasthesia generalized and bilateral with lip numbness.

Any other testing?

Is this adequate to rule out a SAH?  Is SAH part of the differential?
Could the vistiril be a clue to the diagnosis?


Thoughts?


If the headache was a sentinal headache that has preceeded actual bleeding the non contrast CT may not reveal anything substantial. In the old days did they not try a lumbar puncture looking for rbcs in the csf?
The CT does not also uncover much about possible dissections so they would need a radiologic work up too.
The antipsychotic meds could cloud the dx as much as help due to chaulking up some of the neuro S&S as psychotic in nature.
The vascular issues for the head and neck trump all at this point and must be worked through asap.

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RE: November Case - November 14, 2008 2:37:03 AM   
bonez

 

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quote:

ORIGINAL: Dnorwood

I she taking the medications as directed?  Is she abusing the vistiril or the atrovent thus causing an interaction between the two?  Forgive my ignorance, but what is SAH in reference to?


A subarachnoid hemmorrhage is what I believe  the good doc is referring to.

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RE: November Case - November 14, 2008 6:00:41 PM   
Long Tracts

 

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Anyone mentioned multiple sclerosis yet?

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RE: November Case - November 14, 2008 7:26:23 PM   
Sebastian Asselbergs

 

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Long Tracts - nope, didn't see that mentioned anywhere here. Why?

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RE: November Case - November 15, 2008 3:27:50 PM   
Dr.Wagner


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The answer to this nice warm up case is...Migraine with Aura.

This is a common case in the ER, but unfortunately so common, that it creates a level of comfort that can be deadly.
The visual deficit that resolves is very typical of true migraines, but when they occur, usually patients are essentially concerned they are having a "stroke".
Every aspect of the physical exam will be normal with regards to the motor exam (I should have included that), with generalized or nonspecific parasthesia being fairly common on the sensory aspect.
In this patients case, the non anatomic tingling and "tongue" sensations were related to the medication Vistiril...which is a common non addictive anti-anxiety medication used in psychiatry (yes it is an antihistimine and the side effect of drowsiness is used to its advantage).
The sinusitis was added as a TRIGGER for the migraine...as migraines have a hundred different triggers.

Triptans are the typical treatment for true migraines and may be used in this case.

The differential of MS is reasonable if this was progressive over time.  Clearly a good thought.

Non Contrast CT is the diagnostic test of choice...but MAY miss SAH and if so inclined or VERY suspicious, a Lumbar Puncture would be performed to look for an abundance of RBC's in the CSF. 
A MRI can be performed as an outpatient and would not be a bad follow up if so inclined.


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RE: November Case - November 17, 2008 12:13:49 AM   
jma

 

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Definitely a nice one Dr. Wagner, especially the medication information. Keep them coming.

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