zaki
Forum Guru
Topics: 92
Posts: 398
|
A 29-year-old man is brought to the emergency room by his girlfriend after developing a severe headache while dancing. The headache began very abruptly, stopping him in his tracks. He was momentarily stunned and is vague about the next events. His girlfriend helped him to sit down, at which time he had a very severe diffuse headache that was worse at the top of his head and in his neck. He went to the bathroom and vomited. He reports that he has previously had three attacks of severe unilateral throbbing headache preceded by visual symptoms. During these episodes, he first noted bright white and yellow shimmering lines to the side of his vision (twice on the left and once on the right). The lines enlarged and moved slowly across his vision for about 20 to 30 minutes. As the lines faded, he developed a severe unilateral throbbing headache, once accompanied by vomiting.
Two hours later, he still has the headache. Physical examination is normal, but he does report photophobia and nausea as well as headache. Computed tomography without contrast material is normal.
The next step would be:
(A) Dihydroergotamine, 1 mg intravenously
(B) Prochlorperazine maleate (Compazine), 10 mg intramuscularly, and meperidine (Demerol), 50 mg intramuscularly
(C) Magnetic resonance imaging
(D) Lumbar puncture
(E) Sumatriptan (Imitrex), 1 ampule subcutaneously
___________________
Maverick
|
|
|
lumbar puncture to rule out sah
|
| usmlebuzz
Forum Elite
Topics: 93
Posts: 263
|
(E)
:|
|
| doc4life
Forum Guru
Topics: 131
Posts: 240
|
This is a case of acute attack of migraine. So the correct answer will be (E.) sumatriptan.
|
| zaki
Forum Guru
Topics: 92
Posts: 398
|
Lumbar puncture is right as guess mention to rule out sah.
Although this man has a history of typical migraine with aura, the present episode has a high likelihood of being due to subarachnoid hemorrhage. Some investigators have wondered if there is an increased risk of brain aneurysms and other vascular lesions in patients with migraine, but the data on this point are inconclusive. Key features that suggest the possibility of subarachnoid hemorrhage are onset during vigorous activity, very abrupt onset of headache, cessation of activity or memory at onset, and early vomiting. The present bilateral headache is different from his prior attacks. Although a severe migraine could have caused the attack, subarachnoid hemorrhage is such a severe life-threatening and yet treatable disorder that it is imperative to exclude it by lumbar puncture before proceeding.
If computed tomography (CT) is available, a scan prior to lumbar puncture is useful. If CT shows subarachnoid blood, a lumbar puncture is not mandatory but may yield useful data about the cerebrospinal fluid pressure and quantity of blood. In patients with small subarachnoid hemorrhages, the CT scan is often normal, as it is days after bleeding. If CT is negative, a lumbar puncture is required to exclude subarachnoid hemorrhage. If CT is unavailable, lumbar puncture can be done safely in patients who are alert and have no major focal neurologic signs.
___________________
Maverick
|
|
|
good qs and nice explanation
|
| carla
Forum Newbie
Topics: 0
Posts: 20
|
Lumbar tap is indicated. You miss to point out thou that in this particular episode the headache was diffuse (he has had it another times Unilateral no neck involvement) and the neck pain.....alone it is telling you that meningeal irritation is occurring.
___________________
Carla
|
| zaki
Forum Guru
Topics: 92
Posts: 398
|
thank you for pointing out this point
___________________
Maverick
|
| zaki
Forum Guru
Topics: 92
Posts: 398
|
thanx carla
___________________
Maverick
|
|
| |
| | | | | | | | | |
