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Post by kemple on Jul 22, 2015 22:23:51 GMT -5
21 yo female comes in w HA for the past 2-3 weeks, has hx of bipolar with schizoaffective, mood d/o, and depression. Has not had any trauma, no numbness or tingling, no fevers or chills just occipital HA for 2-3 weeks. Past week intermittent vomiting but nothing continuous. Went to Urgent care about 9 days ago sent home, went to ED about 6 days prior had CT brain, CBC, BMP, LFT, UA/UPreg all negative. Still no nuchal rigidity however now having intermittent visual changes as well. No other history.
Allergies:
None
Meds:
Lithium
Lamictal
Celexa
Zofran
Social Hx:
1/2 ppd smoker
minimal alcohol
denies recreationals
Fam Hx:
Noncontributory
And go....
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Post by Bjs04f on Jul 23, 2015 9:57:45 GMT -5
Lithium level is? other thought is CST, needing MRV brain to eval cavernous sinuses, the more I read about that the more subtle some of these are
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Post by slevittMD on Jul 23, 2015 12:22:22 GMT -5
I'm with Stransky, not thinking too much more in depth for zebras until I have a lithium level. Anytime a patient is on lithium, they need a level, but especially if they're presenting with vague complaints. I have already had a patient come to me in the ED who had been discharged from another ED that couldn't figure out what was wrong (They ignored a creatinine around 3) and I sent them to TTH for dialysis for lithium toxicity.
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Post by kemple on Jul 23, 2015 18:39:26 GMT -5
Lithium is normal, I can tell you in advance your MRV was normal as was MRI. I did dx this pt in the ED though.
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Post by Bjs04f on Jul 23, 2015 19:40:34 GMT -5
alright so not lithium we look good for cavernous sinus, no signs of increased ventricles on initial ct i assume. So anything on physical ie neuro or optho things. what was she doing when headache first started
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Post by Bjs04f on Jul 23, 2015 19:42:41 GMT -5
whats her vitals, any other history with this (increasaed urination, inc thirst, hair endocrince changes)
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Post by tyson on Jul 24, 2015 3:39:58 GMT -5
I would look at symptoms for increased ICP. papilledema? HA w/ positional changes? LP?
Could potentially consider MS. does it fit w/ optic neuritis? and other weird sensory deficits that she's had in previous months?
Side effect of medications? Any of these meds new?
or....
maybe she's just nuts, write it all off to bipolar/mood disorder and tell her to follow up with your wife.
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Post by kemple on Jul 24, 2015 9:06:39 GMT -5
Lp has opening pressure greater then 65..started coming out of the top. There is more to it than simple ich though. Keep thinking you're all close. (except Levitt who knows the answer now).
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Post by kemple on Jul 24, 2015 9:07:43 GMT -5
Btw vitals and endocrine normal.
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Post by Bjs04f on Jul 24, 2015 9:57:22 GMT -5
alright so normal MRI/CT rules out intracranial lesion or hemorrhage for ICP. Leaving cerebral edema from perhaps hyponatremia/psychogenic polydypsia, or perhaps an undiagnosed encephalitis/meningitis with scarring, or pseudotumor cerebri
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Post by kemple on Jul 24, 2015 10:36:11 GMT -5
It's ich but from what.....
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Post by pbruss on Jul 24, 2015 15:02:17 GMT -5
lamictal?
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Post by kemple on Jul 25, 2015 16:19:06 GMT -5
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Post by jpollock on Jul 27, 2015 20:36:17 GMT -5
HA for 2-3 weeks (not chronic headaches) and vision changes = look for papilledema Since most of us suck at looking for papilledema consider something more reliable like LP or use ultrasound (remember you can use the linear probe to measure the optic nerve sheath 3mm behind the globe. It should be 5mm or less. anything greater is elevated ICP. Go to www.sonoguide.com for a quick overview) |
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Post by erwoody on Jul 28, 2015 6:11:56 GMT -5
could be this month's winner for "case of the month" for a bottle of wine
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