Level 3: Headache – Contrasting Case #1: 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 30 year old G1P1 female reporting to her primary care office for evaluation of a headache she has had for the past few weeks.

HPI: The patient describes her headache as a dull ache located on the top of the head. She has noticed some changes in her vision over the past few weeks. She denies any recent head trauma. She reports she has had a few episodes of emesis over the past week, particularly in the mornings. She has also had a few episodes of dizziness. She denies any photophobia or phonophobia with her headache. She denies any muscle weakness or paresthesias. She denies any loss of consciousness. She denies any changes to bowel or bladder habits. Patient denies any neck stiffness or tenderness.

PMH: No Illnesses and no medications.

FMH: Mother, age 58, diagnosed with DM and HTN; Father, age 60, diagnosed with DM and HLD; reports extensive family history of diabetes and hypertension

SH: Noncontributory

ROS: As per HPI

General: Female patient appearance consistent with age. Patient is cooperative, and in no acute distress during interview.
Vital Signs: BP:130/80, P:70, RR:18, BMI:35, T:100.9
HEENT: Normocephalic, atraumatic, PEERLA bilaterally. EOM intact bilaterally. No nuchal rigidity. Negative Brudzinski’s and Kernig’s signs.
Funduscopic: Optic disc visual bilaterally. Papilledema present bilaterally. No A/V nicking present.
Respiratory: Normal respirations present, no accessory muscle use. Normal, vesicular breath sounds present in all lung fields bilaterally. No wheezes, rales, or rhonchi present.
Neurologic: Cranial nerves II – XII grossly intact bilaterally. Muscle strength is 5/5 in the upper and lower extremities bilaterally. DTRs are 2/4 in the upper and lower extremities bilaterally. Proprioception and coordination grossly intact bilaterally.

CSF – elevated opening pressure; normal glucose and proteins; no growth on media
CT (head) – see below