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  • 1. Headache
    • Zeina Arnouk, MD.
    • PGY 1, Internal Medicine
    • Wayne State University, Crittenton Hospital
    • 07/20/2011
  • 2. CC:headache HPI:patient came to the ER because of worsening headache, that started 5 days ago, on the left side of the head and now radiating to the right side of the head, scoring 9/10, pressure like, continues ,gradual increasing, tylanol could not relief it.
  • 3.
    • The headache was associated with:
    • N/V, photophobia, light sensitivity.
    • Also with fever, chills, night sweats.
    • No history of trauma, or sick contact.
    • Headache was not associated with aura.
  • 4.
    • PMD: Depression.
    • PSH: carpel tunnel surgery.
    • Allergy: none.
    • Medications:
    • 1.Sertraline.
    • 2.Gabapentin.
    • FH: None.
    • SH: smoking for 20 y 1pach/day
    • Alcohol: only on weekends.
    • Drugs: none.
  • 5. ROS: GEN: fatigue, subjective weight loss, fever, chills, night sweats. Skin: rash on her forehead, left side. Ears: no hearing loss, no tinnitus. Mouth: no sore throat. Chest: no chest pain, palpitations, no SOB. GI:N/V, constipation. GU: none. Neuro: numbness in the left hand, no seizure, no paralysis, no memory loss.
  • 6.
    • Headache classification :
    • 1.primary headache.
    • 2.secondary headache.
  • 7.
    • 1.primary headache syndromes:
    • A. tension headache.
    • B. migraine.
    • C. cluster headache.
  • 8.
    • Secondary headache causes:
    • 1.intracranial:
    • -trigeminal neuralgia.
    • -vascular.
    • -Infection.
    • -Tumor.
    • 2.extaracranial:
    • -sinusitis.
    • -Temporal arthritis.
    • -TMJ (temporomandibular joint dysfunction syndrome)
    Crittenton hospital
  • 9.
    • Physical examination:
    • VS: T:97.8, HR:43, BP:127/56, RR:18, O2:99%room air.
    • Patient is alert and oriented X3.
    • HEENT: Red rash with few vesicular lesion, it is painful, over the left forehead.
    • Lymphoadenopathy in the same side
    • -retro auricular and occipital area.
    • -jugular area.
    • Patient has mild nuchal Rigidity,
    • No thrush in mouth.
  • 10.  
  • 11.
    • All: heart, chest, abdomen, extremities exams were normal.
    • Neuro exam:
    • Non focal, intact cranial nerves from 1 to 12.
    • Kerning's sign: was negative.
    • Brudzinski’s sign: wss negative too.
    • Jolt accentuation of headache:
    • Negative too.(and this is the most sensitive sign)
  • 12.
    • CBC
    • Chemistry
    • Imaging
    • CSF study
    • Other
  • 13.
    • WBC:8.9
    • RBC: 4.23.
    • Hgb: 13.7.
    • Hct: 40.4.
    • Plt:143.
  • 14.
    • Glu:99
    • Na: 141.
    • K: 3.8.
    • Chloride:107.
    • BUN:17.
    • Cr:0.6.
    • AST: 16.
    • ALT:11.
    • ALK:65.
  • 15.
    • Head CT scan: No evidence of intracranial hemorrhage, acute infarction, mass or midline shift. the ventricles and basal cisterns are within normal limits. the visualized portions of the Paranasal sinuses and mastoid air cells are clear.
  • 16.
    • CSF : color was clear.
    • WBC:433(<500).
    • RBC:none.
    • Lymphocyte:98(>50).
    • Monocyte:2.
    • Protein: 106.1(80-100), Glu: 50(N)
    • CSF culture:+3 WBC
    • No PMN’s seen on smear.
    • No organism seen.
    • Smear was prepared by cytospin method.
  • 17.
    • Viral meningitis:
    • 1.entero meningites.
    • (polymorphonuclear predominance )
    • (same sy and diarrhea, or UR symptom)
    • 2.HIV:give like mononucleosis like syndrome.
    • 3.herpes simplex : most of the are HSV-1,and with HSV-2 we see primary genital herpes in 85%.
    • Others: syphilis, lyme, fugal….
  • 18.
    • PCR study:
    • VZV: not detected.
    • HSV: not detected.
  • 19.
    • Coagulation studies:
    • 1.PT: 10.2
    • 2.INR: 2.1
    • PTT: 66
  • 20.
    • Viral mengitis:caused by
    • Enterovirus, HSV, HIV, west nile virus, VZV.
  • 21.
    • Enteroviruses — Aseptic meningitis the most common cause of viral meningitis .
    • Cerebrospinal fluid (CSF) findings are typical of other viral meningitides and include a white blood cell (WBC) count that is generally less than 250 cells/microL, a modest elevation in CSF protein concentration (generally less than 150 mg/dL), and a normal glucose concentration.
  • 22.
    • Herpes simplex meningitis — Primary HSV has been increasingly recognized as a cause of viral meningitis in adults. In contrast to HSV encephalitis, which is almost exclusively due to HSV-1, viral meningitis in immunocompetent adults is generally caused by HSV-2.
    • genital lesions are present in approximately 85 percent of patients with primary HSV-2 meningitis and generally precede the onset of CNS symptoms by seven days. The CSF profile includes a pleocytosis with a predominance of lymphocytes, and a normal CSF glucose concentration .
    • HSV meningitis can also occur without evidence of genital lesions, although this is less common.
  • 23.
    • Suspected viral meningitis — The approach to empiric therapy in the patient with viral meningitis will depend upon the clinical appearance of the patient and underlying host factors. Patients who are elderly, immunocompromised, or have received antibiotics prior to presentation may be considered for empiric therapy for 48 hours, even if viral meningitis is the suspected diagnosis. Otherwise, the clinician can consider observing the patient without antibiotic therapy.
  • 24.
    • If HIV is a diagnostic consideration, then blood testing for HIV RNA and HIV antibody should be performed. (See &quot;Diagnostic assays for HIV infection&quot;  and &quot;Techniques and interpretation of HIV-1 RNA quantitation &quot; .)
    • If aseptic meningitis due to HSV is suspected (eg, concomitant genital lesions), empiric therapy with acyclovir  (10 mg/kg intravenously every eight hours) can be administered. (See &quot;Acyclovir: An overview&quot; .)