43: Headache

A 31 year old male presents to the ED with a headache.  He states he rarely gets headaches, but has been having on and off headaches all week.  Tonight, after sexual intercourse, he developed a sudden headache, which is still present.  He denies fever, but has vomited twice.

On exam his vital signs are normal.  You think his neck may be a little stiff, but he can bend his chin to his chest.  The rest of his exam, including a full neurological exam is normal.

CBC and metabolic panel are normal.  The CT scan is read by the radiologist as normal (Image below) so you recommend an LP, but the patient refuses despite all the terrible things you tell him may happen to him.  He says he has been using his iPhone to research headaches and thinks he has a “Post-coital headache”, which he read is not dangerous.

What should you do next?  Is there anyone you should call to help you?

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A 56 year old man presents with 2 months of worsening dyspnea on exertion.  Now he can’t even go up the stairs without getting severely short of breath.   There is no fever, cough, chest pain, leg swelling or other symptoms.  He has no past medical history and his only medication is a steroid cream for a skin condition.

On exam he is afebrile with a pulse of 108, a BP of 118/70, respirations at 20, and a pulse ox of 94% at rest.  His lungs are clear without rales or wheezing, his heart is regular without murmur and his legs have no swelling, tenderness or cords.  The rest of his physical exam is normal.

His CXR & EKG are shown below.  What condition or conditions should you worry about and in what order.  Is his presentation “typical” or “atypical”?

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 A 42-year-old man injures his ankle on a slope.  He lost his balance and fell.  He’s not sure if it inverted or was rotated externally or all both.  He denies and other injuries, but is unable to bear weight.

On exam he has a good pulse and skin is intact without echymosis and the compartments are soft.  His ankle is tender bilaterally with mild swelling.  The foot is not tender.

His x-ray is shown below.

What type of injury to you see?

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