History and Physical — Patient 28

History

Present Illness: The patient is a 36 year old right-handed white female who presents with a one month history of severe headaches that worsen upon standing or sitting. When recumbent, the headaches improve, often completely resolving. The patient describes a typical headache as a dull, generalized pain, frequently with an additional pulsating quality. The headaches occur daily, last for hours, and are accompanied by fatigue and nausea. She denies visual changes, tinnitus, weakness, numbness, fever, chills, vomiting, weight loss, menstrual abnormalities, bowel or bladder incontinence or gait abnormalities. She likewise denies a history of recent trauma, concurrent medical problems, or prior headaches. While she was involved in a low speed MVA approximately four months prior to admission, she did not strike her head in the accident and did not seek medical attention.

One month ago, the patient awoke with her initial headache which lasted for approximately nine hours and resolved spontaneously. One week later she had a similar but more severe headache lasting for 23 hours. At that time she noted the headache was worse upon standing but could be slowly relieved by lying down. She visited a local ER where a CT scan and routine labs were within normal limits. She visited a local neurologist who obtained a MRI of the head. When the MRI showed diffuse meningeal enhancement, she was referred to Baylor College of Medicine for possible meningeal biopsy. She continues to experience daily headaches, precipitated by standing, and currently remains supine for much of the day.

Past Medical History: Significant for hypothyroidism, occasional low back pain and cryosurgery for cervical dysplasia eight years prior to admission.

Allergies: No known drug allergies.

Medications: Synthroid.

Social History: She is married, has two healthy children, and works as a respiratory therapist. She does not smoke, drink or use illicit drugs. She denies excessive caffeine intake.

Family History: There is no family history of headaches, cancer, or cardiovascular or neurological disease.

Physical Exam

General: The patient is a well-developed, slightly obese white female in no distress when supine, but with a mild headache when sitting.

Vital Signs: B.P. 110/60; pulse 72; temperature 97.8F; respirations 18.

HEENT: Normocephalic, atraumatic, sclerae anicteric, fundus appeared normal with sharp discs. Her neck was supple without lymphadenopathy, thyromegaly or carotid bruits.

Chest: Lungs are clear to auscultation and percussion bilaterally.

Cardiovascular: Regular rate and rhythm without rubs, gallops, or murmurs.

Abdomen: Soft and non-tender without palpable masses or organomegaly.

Neurological Examination

Mental Status:

Area

Findings

AttentionIntact.
LanguageFluent with intact comprehension, repetition, naming, reading, and writing.
MemoryIntact recent and remote memory.
Constructional AbilityIntact.
Abstract ThinkingIntact.
Calculation AbilityIntact.
PraxisIntact.

 

Cranial Nerves:

Cranial Nerves

Findings

INot tested.
IIVA 20/40 OU; visual fields intact; pupils 3mm and reactive bilaterally; fundoscopic exam is WNL without signs of papilledema.
III / IV / VIEOMs intact in all directions, no diplopia or nystagmus.
VSensation intact to LT/PP, masseter strength nl.
VIISmile is symmetrical.
VIIIHearing grossly intact to finger rub bilaterally.
IX / XPalate rises symmetrically, gag intact.
XISCM 5/5, trapezius 5/5 bilaterally.
XIITongue midline without atrophy.

 

Motor: Normal bulk and tone throughout. There was no tremor or cogwheel rigidity. Strength testing of both the upper and lower extremities were normal (5/5).

Reflexes: 2+/2+ for upper and lower extremities.

Sensation: Intact to LT/PP/Vibration/position in all extremities.

Cerebellar: Intact finger-nose-finger, heel-shin, and rapid alternating movements.

Gait: Normal station, step, stride, turning, toe, heel, tandem, and arm swing.

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