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A
25 year-old female law student experiences the following episode 24 hours
after completing the bar exam. Initially she notes flashing lights beginning
the right visual field slowly moving across to the left followed by an
area of blindness. This is followed by a left orbital throbbing headache,
which builds up to maximal intensity within 3 hours and is associated
with nausea and vomiting. Activity makes the headache worse and she prefers
to be in a dark room. Family history indicates mother and father have
"migraine". Patient had "motion sickness" as a child. Neuro exam is normal,
neck is supple, VS are normal, no bruit is appreciated in her neck or
head.
You are working in the ED
and she has waited 4 hours to see you as a "neurologic consultant".
Images
- What do you tell this patient
when she explodes verbally at you for allowing to suffer for so long?
- Are these diagnostic test
indicated and for what purpose as you need to explain these to the patient?
CT
MRI LP
MRA
Carotid ultrasound
ESR
Coagulation studies
Antiphospholipid antibody studies
Urinary catecholamine
Urinary HIAA
EEG
- What is the differential
diagnosis?
- She demands Demerol and
Phenergan because that is what her mother is treated with for her headache.
What is your response?
- You suggest Imitrex tablets
but she says she is too nauseated to take oral meds. What do you do
in this situation?
- While thinking about what
to do next, the CT that the ED doc ordered but forgot to tell you about
is presented to you. Ten minutes later, your chest pain and palpitations
abate and you need to explain this CT and it significance to the patient?
- Define
cluster
migraine with aura
migraine without aura
scintillating
scotoma
spreading cortical depression
tension headache
hypertensive crisis
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C-11 - Revised
6/22/05
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