Level 2: 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 presents to the ER with reports of headache over the past few weeks. The patient has difficulty focusing during the interview. He is accompanied by his wife who confirms that he has been acting differently over the past month.

History of Present Illness: The patient is able to answer questions, but appears to have trouble focusing. The patient reports his headache feels like a “dull ache” and does not change location or character. He denies any pain radiation into his face or neck. He does not notice a specific trigger or inciting event for the headaches. He was involved in a motor vehicle accident 6 months prior. He has had some minor memory problems since his accident. He denies any recent head trauma; however, he did recall losing consciousness once over the past month in which he fell out of a chair. His loss of consciousness was witnessed by co-workers, who report he had some shaking of his arms and legs during the episode. He did not lose bowel or bladder continence during his episode of unconsciousness. He denies having seizures in the past. He also reports muscle weakness and easy fatigability lately. He reports decreased urinary frequency. He denies nausea, vomiting, or dizziness. He also denies neck stiffness, weakness or paresthesias.

Review of Systems –
HEENT: Denies dizziness, lightheadedness, or head trauma. Denies changes in vision or hearing. Denies rhinorrhea, epistaxis, or seasonal allergies. Denies trouble swallowing or sore throat.
Urinary: Reports decreased frequency. Denies hematuria, or weak stream.
Musculoskeletal: Reports some muscle weakness and easy muscle fatigue. Denies joint pain.

Physical Exam –
Vital Signs: BP:130/80, P:70, RR:18, BMI:30, T:98.7
HEENT: Normocephalic, atrumatic, PEERLA bilaterally. EOM intact bilaterally. No nuchal rigidity. Negative Brudzinski’s sign.
Fundoscopic: Optic disc visual bilaterally. No cupping or papilledema present. No A/V nicking present.

Tests –
Plasma osmolality: <280
Urine osmolality: >150
Urinalysis: dark, concentrated urine