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Left Retro-orbital Pain

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History of Present Illness:

A 62-year-old female with a history of DM and HTN is brought to the emergency department by family for a headache on the left side of her head that came on gradually and has been constant for the past 5 days. Yesterday her daughter noticed there is redness to the left eyelid. She denies any photophobia, but reports nausea and one episode of emesis. She has no history of similar headaches.  She denies  or other complaints.

Vital Signs & Physical Exam:

Vital signs are normal except for temperature of 37.3   Physical exam is otherwise normal except for mild redness to left upper eyelid and left side of scalp

Initial Differential Diagnosis:

  • Shingles
  • Meningitis
  • Syphilis, the great imitator

Initial Diagnostic Testing:

  • Labs: CBC: normal, ESR: 30, BMP: normal except for sodium 130, CRP: normal
  • Imaging: CT brain: normal
  • CSF:  9 WBC and 155 RBC in tube 1.  2 WBC and 300 RBC in tube 4

QUESTIONS:

  1. What do you think about the lab results?
  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?

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ANSWERS:

  1. What do you think about the lab results? The cell counts don’t make sense so call the lab to have them reanalyze the CSF
  2. What should you do next?  Treat with acyclovir while awaiting CSF reanalysis
  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:

  • Repeat CSF analysis: 140 WBC (small lymphs that were counted as RBC’s initially).
  •  MRA Brain: Normal
  • Sendouts: CSF HSV: negative.  CSF VZV: positive.

CASE LESSONS: If something doesn’t “fit”, keep thinking and look for a reason

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