51 year old man comes to the office complaining of a " migraine headache" that he's had over the past 3 days. THe headache is severe, right sided, posteriorly for the most part, sometimes frontal, associates with nausea, vomiting, some blurred vision. Not worse with bending forward, no photo/phonophobia, no sinus drainage. Took Acetaminophen with codeine without any relief.
He had migraine headache before but nothing like this. " this is the worst headache I've had in my life" states the patient.
He is otherwise healthy, moderately overweight, non smoker, does not drink.
Physical exam reveales middle aged man, in obvious distress, fully alert and oriented. BP 130/70, HR 80, afebrile. neuro exam is non focal, limited( nondilated) funduscopic exam normal. The rest of physical exam is also unremarkable.( no nuchal rigidity, Brudzinski neg)
caz-headache
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originaltup
- elder
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- Location: Ohio
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otalen
- senior
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- Joined: Sun Jul 06, 2003 1:10 pm
initial ma gandisem la ceva de genul carbamazepinei, in eventualitatea unei nevralgii (ca si cea de trigemen), dar nu prea merge.
pt sumatriptan ar trebui sa excludem eventuale cauze vasculare hemoragice, mai ales data fiind varsta pacientului. chiar daca nu are semne focale. ce-i drept nu stiam ce e sumatriptanul dar am gasit pe medscape.
am aberat cumva??
pt sumatriptan ar trebui sa excludem eventuale cauze vasculare hemoragice, mai ales data fiind varsta pacientului. chiar daca nu are semne focale. ce-i drept nu stiam ce e sumatriptanul dar am gasit pe medscape.
am aberat cumva??
"Dont't just Do something, Sit there!"
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cerbu
- elder
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evident CT scan e raspunsul. gluma e ca omul a zis chestia cu cea mai rea durere de cap fara sa fie intrebat si a repetat de 3 ori!
rezultatul:
6.0 by 1.2 cm subdural hematoma right posterior fosa.
moment in care pacientul a fost trimis in camera de garda la un spital care are neurochirurgie. oamenii din camera de garda, desi aveau copiile de la CT, nu au avut incredere( si bine au facut)
CT repetat in aceesi zi a fost interpretat de alt radiolog ca:
" increased atenuation in the region of the subdural space and posterior fossa. possibilities include prominent and possibly throbmosed transverse sinus, or a subdural hematoma"
intre timp( 5 ore mai tarziu) cefaleea s-a accentuat, pacientul a inceput sa dea semne de delir.
MRI/MRV a fost interpretat:
At the posterior aspect of the superior sagital sinus at approximately the level of the centrum semiovale there is lack of flow with throbmus. This extends inferiorly toward the torcula and over into the right transverse sinus down into the right jugular vein. this is compatible with superior saggital sinus and right transverse sinus thrombosis. no subdural hematoma.
pacientul a primit heparina intravenos, apoi warfarin. workup pentru hypercoaguable state a fost negativ( inclusiv protein S, C, factor V Leyden, Prothrombin gene mutation, antiphospholipid, homocysteine).
concluzii:
1. asculta-l pe pacient chiar daca esti ocupat in office. e greu, pentru ca destul de multi sunt cam nebuni si ipohondrii, norocul astuia a fost ca e om normal si nu vine de doua ori pe saptamana.
2. CT scan nu e un test perfect( putea sa nu arate nimic-a fost noroc pur). de asemenea, pentru subarachnoid, daca CT e negativ si inca suspectezi hemoragie are nevoie de punctie lombara.
3. 7 luni dupa povestea de mai sus omul traieste, e inca pe warfarin( va fi pe viata), inca are dureri de cap( nu asa rau) dar tromboza a scazut in dimensiune( a avut 2 MRV follow-up)
rezultatul:
6.0 by 1.2 cm subdural hematoma right posterior fosa.
moment in care pacientul a fost trimis in camera de garda la un spital care are neurochirurgie. oamenii din camera de garda, desi aveau copiile de la CT, nu au avut incredere( si bine au facut)
CT repetat in aceesi zi a fost interpretat de alt radiolog ca:
" increased atenuation in the region of the subdural space and posterior fossa. possibilities include prominent and possibly throbmosed transverse sinus, or a subdural hematoma"
intre timp( 5 ore mai tarziu) cefaleea s-a accentuat, pacientul a inceput sa dea semne de delir.
MRI/MRV a fost interpretat:
At the posterior aspect of the superior sagital sinus at approximately the level of the centrum semiovale there is lack of flow with throbmus. This extends inferiorly toward the torcula and over into the right transverse sinus down into the right jugular vein. this is compatible with superior saggital sinus and right transverse sinus thrombosis. no subdural hematoma.
pacientul a primit heparina intravenos, apoi warfarin. workup pentru hypercoaguable state a fost negativ( inclusiv protein S, C, factor V Leyden, Prothrombin gene mutation, antiphospholipid, homocysteine).
concluzii:
1. asculta-l pe pacient chiar daca esti ocupat in office. e greu, pentru ca destul de multi sunt cam nebuni si ipohondrii, norocul astuia a fost ca e om normal si nu vine de doua ori pe saptamana.
2. CT scan nu e un test perfect( putea sa nu arate nimic-a fost noroc pur). de asemenea, pentru subarachnoid, daca CT e negativ si inca suspectezi hemoragie are nevoie de punctie lombara.
3. 7 luni dupa povestea de mai sus omul traieste, e inca pe warfarin( va fi pe viata), inca are dureri de cap( nu asa rau) dar tromboza a scazut in dimensiune( a avut 2 MRV follow-up)
Last edited by cerbu on Wed Mar 17, 2004 2:45 pm, edited 1 time in total.
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plure
- junior
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O cefalee nou aparuta la varsta lui cere CT. Nu are criterii de durere migrenoasa (nu repetabilitate, nu fotofobie, etc).
Images of innocence and terror, not easily described in words alone, nonetheless "speak" across time, space and culture with a power to give meaning to otherwise meaningless facts.
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