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Pulsatile Headache

UnFiNiShEd CaSe CoMe BaCk LaTeR

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History of Present Illness:

A man in his 60s presents to the ED for 24 hours of vomiting and pulsatile left sided headache associated with some blurred vision.  He went online and read it could be a migraine and should get better within 24 hours.  It didn’t get better so he came to the ED.He denies any weakness, fever or other complaints.

Vital Signs & Physical Exam:

Vital signs are normal except for a pulse of 44.  Exam is normal except for severe left sided ptosis with difficulty moving the eye medially or superiorly

Initial Differential Diagnosis:

  • Carotid dissection
  • Brain aneurysm

Initial Diagnostic Testing:

  • Imaging: see CT angio below

QUESTIONS:

  1. What does the case image show?  
  2. What should you do next?  
  3. Want a 1-minute consult/tutorial on this case? 
  4. Want to know what happened with this patient?

SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT

 

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ANSWERS:

  1. What does the case image show?  The image shows a pituitary mass with a blush that could be a bleed.  See arrow on image below
  2. What should you do next?  Consult neurosurgery
  3. Want a 1-minute consult/tutorial on this case?  See yellow area from sample page below.
  4. Want to know what happened with this patient?  See case conclusion below tutorial page.

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

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CASE CONCLUSION: given pain medicine, nausea medicine, steroids and admitted for urgent but not emergent surgery

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