History of Present Illness:
A man in his mid 30’s with a family history of migraines presents to the ER with 1 day of bitemporal headache and vomiting. He denies fever, focal weakness or other complaints other than a mild sore throat. The headache has been gradually worsening since yesterday and is now severe. The triage nurse charts that he has a history of headaches, but he says he has never had to come to the ER for one.
Vital Signs & Physical Exam:
Vital signs are normal except for mildly elevated BP. When you walk into the room, this is what you see.
What is the most likely diagnosis?
- A) Migraine
- B) Meningitis
- C) Monoxide (CO toxicity)
- D) Mass
SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT
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Emergency Medicine 1-Minute Consult, 5th edition
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QUIZ ANSWER: What is the most likely diagnosis?
- A) Migraine – can cause photophobia, but typically not this severe. Should always be a diagnosis of exclusion in an ER patient especially if they have never been to the ER for it.
- B) Meningitis – CORRECT. In a patient with symptoms concerning for meningitis if the photophobia is severe enough that they want to keep a blanket over their head and or their eyes closed most of the time, strongly consider an LP
- C) Monoxide – always a good though with headache, especially during cold weather
- D) Mass – unlikely to present this acutely
1-Minute Consult on this topic: Click HERE and scroll to pg 153.
CASE CONCLUSION: CSF had normal protein and glucose but 40 WBC and 160 RBC. Culture and CSF panel eventually came back negative (included HSV1, HSV2, VZV and others)