Confusion & Shaking*

History:

An otherwise healthy 32-year-old female presents to the ED for sudden shortness of breath, confusion and shakiness.  She was recently diagnosed with migraines due to recurrent left-sided headache.

Exam:

Vital signs are normal .   Exam is normal.

Relevant Test Results:

  • EKG: none
  • Labs: none ordered
  • Imaging: none

What is the most likely diagnosis?

  • A) Anxiety
  • B) Migraine
  • C) Seizure
  • D) Drugs
  • E) Stroke

SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT

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QUIZ ANSWER:

  • A) Anxiety
  • B) Migraine
  • C) Seizure
  • D) Drugs
  • E) Stroke – CORRECT –  The image shows basal ganglia mass v. CVA on the left (side of her “migraine”).  MRI shown below with reading 

1. Subacute left basal ganglia infarct.
2. Multiple small left MCA territory cortical infarcts.
3. Likely small chronic right cerebellar infarct.

1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

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CASE CONCLUSION: Admitted for stroke workup including PFO, hypercoaguable state and dissection among other conditions.  Had a positive hypercoaguable work-up and was started on Eliquis.

CASE LESSONS:

  1. Young people do get strokes
  2. Posterior circulation stokes may present in odd ways.  Headache is common and often mimics migraine.  Involuntary movement can mimic a seizure.