Level 1: Headache – Contrasting Case #3: Patient Information

Given these changes from the original case, what is your diagnosis?

What is your diagnostic explanation?

As compared to the long case, this patient is a 57 year-old previously healthy woman who presents to the urgent care clinic with a 2-day history of headache and malaise. Headache is described as a constant, dull ache of 5/10 severity and retro-orbital location. She reports mild myalgias and weakness, and worsening fatigue over the same time period. She has not checked her temperature, but has felt slightly feverish. She also reports that since this morning she has experienced a dry cough with associated pleuritic chest pain, but denies hemoptysis. She has not yet received her flu shot this year.

PE: low-grade fever (100.8F) and tachycardia (110 bpm); all other vital signs are within reference ranges. The patient appears fatigued; she is alert, oriented and in no acute distress. Respiratory exam shows dry cough, but no other adventitious sounds on auscultation. The remainder of the exam is unremarkable.