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23-year-old male medical student complains of a headache and intermittent…
23-year-old male medical student complains of a headache and intermittent fever for 2 weeks.
Primary
tension (30min-7 days)
pain is like a band squeezing the head, bilateral.
migrane (4-72h)
pain, nausea, visual changes, unilateral, pulsating, photophobia, phonophobia. Auras.
cluster (15min-180min)
pain is in and around 1 eye, unilateral. lacrimation, rhinorrhea, horner's syndrome.
Secondary
Extracranial
Temporal arteritis (giant cell)
unilateral temporal headache - usually old >50 yo. can lead to blindness
Sinusitis
ENT exam. Flu symtoms.
Otitis Media
Acute close-angle Glaucoma
headache, red eye, corneal clouding
TMJ dysfunction
Headache, jaw stiffness, chronic ear pain
Temporomandibular Joint
Trauma
causes - HIV, TB, dengue
Intracranial
Bleeding
SAH - "worst headache of my life"
subdural
new onset progressive. after trauma
focal symptoms
Space occupying lesion
worse in the morning. progressive. vomitting
Meningitis, Encephalitis
Cerebral venous thrombosis
Hypertension
Hydrocephalus
Trigeminal neuralgia
pain 3 months ago, 3-5sec, unilateral pain on right lip when brushing teeth, radiate to right forehead, no alleviating.
Metabolic
Medication overuse
Post-LP headache
Carbon monoxide poisoning
cherry red skin
Pheochromocytoma
Hyponatremia
Hx
o New onset?
o If patient has history of headaches. Is there any change in headache?
o Fever?
o Nausea/Vomiting?
o Neurological deficits: Weakness, Numbness, Visual disturbances?
o Trauma to head?
o Weight loss?
o On anti-coagulants?
o On OCP?
o Any hereditary bleeding disorders?
o Jaw claudication?
o Others: Seizure? Aura? Travel history?
Focal signs
Frontal - gait, muscle weakness/numbness, broca aphasia
parietal - impairement tactile, read, write, calculating, identify objects, on touch, visual neglect
Temporal - memory tinitus
Occipital - visual, hallucination
Limbic - confusion, emotions
Cerebellar - ataxia, dysdiadokinesia, dysmetria
brain stem - CN Spinal cord - paresis/sensory
PE
Vitals: fever, BP, GCS, MMSE, mental state
Full neurological exam
Check for papilledema
Meningeal - fever, headache, stiff neck, Kernig and Brudzinski signs
Palpate temporal artery for tendernous
Investigation
Bloods - FBC, culture, ESR
Neuroimaging - CT, MRI
Histology - Temporal arteritis biospy
LP