Weekly Case Study - Case 1

Fifty Two year-old Afro-American hypertensive man suddenly developed headache and disequilibrium for 2 weeks despite maintaining compliance with his medications. The headache is located in the occipital region, is dull and aching in a quality and is not associated with visual blurring, nausea or vomiting. It spontaneously dissipated within 2 hours of awakening. One day he awakened with severe pounding headache with vomiting and nausea and light-sensitivity. This headache is associated with diplopia and is clearly a different pattern and type as contrasted with the initial headache. He has difficulty walking due to poor balance but has no leg weakness. PH elevated ­ BP. CHF. Meds - Diuril, Verapamil, Captopril SH-6, beers a day.

NE	MS-awake, alert, attentive gait - broad-based ataxic; neg Romberg motor - no drift, nl strength reflexes - symmetrical; Babinski ¯ ¯ coordination - impaired heel to shin-nl finger to nose CN-no spontaneous venous pulsation on fundoscopy; right facial weakness; right abducens paresis
PE	BP 240/150 mmHg; P-50: R-8/M neck - rigid
CT	Images

Questions:

1.  Based upon symptoms, what are potential mechanisms of these initial and subsequent developing   headaches?

2.  Based upon exam findings what is location in neuro-axis for the lesion?

3.  What does CT findings most likely represent?  Is MRI warranted?

4.  What do vital signs indicate?

5.  Outline treatment options

6.  Prior to CT and MR, how could this diagnosis be established?

7.  What might be the role of lumbar puncture in this patient?

8.  While waiting for the neurology staff to exam the patient, the patient deteriorates.

9.   Is this hypertensive crisis how would this be Rx?

Findings include:	coma
	quadriplegia
	absent dolls-head
	bilateral plantar extensor response
	miotic, but reactive pupils
	ataxic apneustic respirations

What has happened to the patient?