Headache Case

Clinical History and Presentation

A 45-year-old woman present with a complaint of severe headache, fever, nausea, vomiting, and photophobia for the preceding 4 days. Three days prior to the onset of these symptoms, she had a flu-like illness with a sore throat. There was no other pertinent medical or surgical history and she was on no medications at the time. Physical examination revealed an obese female, fully oriented with an oral temperature of 102.3 degrees F. Blood pressure was 128/74 mm Hg; and heart rate was 130 beats per minute. Pertinent findings included mild neck stiffness on forward flexion and a petechial rash involving the back and both lower posterior extremities. The neurological examination did not show any motor or sensory deficit. A lumbar puncture was performed, and the patient was admitted to the hospital.

Admission Data

Questions

1. The urinalysis and the urine sediment in this patient are best characterized as:

   
   a. diagnostic of glomerulonephritis.
   b. diagnostic of a coagulopathy.
   c. diagnostic of renal tubular and/or interstitial disease.
   d. suggestive of urinary tract inflammation or infection.

2. All of the following statements about this patient's cerebrospinal fluid are correct EXCEPT:

   
   a. the cerebrospinal fluid glucose level is within the normal range in relation to the blood glucose level.
   b. the number and proportion of white blood cells are characteristic of a pyogenic infection.
   c. the Gram stain does not show any organisms.
   d. the findings are consistent with aseptic meningitis.

3. The chest x-ray is most consistent with:

   
   a. tuberculosis.
   b. lobar pneumonia.
   c. pulmonary abscess.
   d. no pulmonary pathology.

4. The hematological data in this patient suggest:

   
   a. leukocytosis with an absolute neutrophilia.
   b. leukocytosis with a relatively lymphocytopenia.
   c. leukocytosis with an absolute lymphocytopenia.
   d. all of the above.
   e. none of the above.

Clinical Course

The patient was initially started on antibiotics which were later discontinued upon negative culture results. She was treated symptomatically and her condition gradually improved. By the sixth day of hospitalization, her CBC and urinalysis had returned to normal, her headache had subsided, the rash had disappeared, and her oral temperature was 98.6 degrees F. A CT scan of the head was normal and the patient was discharged 7 days after admission.

Questions

5. All of the following statements about the CNS problem this patient was diagnosed as having are correct EXCEPT:

   
   a. it usually affects patients under age 30.
   b. it is usually a self-limited illness.
   c. it usually leads to impairment of consciousness.
   d. cerebrospinal fluid abnormalities may persist for several weeks in patients who are otherwise asymptomatic.

6. Symptoms and clinical findings related to the CNS problem such as this patient experienced are known to be caused by:

   
   a. fungal infection
   b. viral infection
   c. sarcoidosis
   d. systemic lupus erythematosus
   e. all of the above

7. All of the following statements concerning this patient's condition are correct EXCEPT:

   
   a. the urinary tract infection was the primary cause of her central nervous system problem.
   b. the patient most likely had aseptic viral meningitis.
   c. her elevated temperature and skin rash were most likely due to the same etiology as her central nervous system problem.
   d. in most instances, patients recover completely from this central nervous system problem.

8. The microscopic appearance of the brain of another patient shows:

   
   a. the presence of bacterial organisms.
   b. the presence of an acute inflammatory cell infiltrate.
   c. changes characteristic of a pyogenic process.
   d. none of the above.