History of Present Illness:
A woman in her mid 20’s presents to the ER for 10 days of generalized headache, nausea, shakiness and intermittent vertigo lasting only seconds. She is 2 months post partum. She denies any fever, vomiting, abdominal pain, focal CNS complaints or other concerns but says the headache is severe. She has a past medical history of depression and asthma and statess she has been under a lot of stress juggling running her business and a new baby.
Vital Signs & Physical Exam:
Vital signs are normal. Physical exam is normal including finger-nose, Romberg, cranial nerves and gait.
Initial Diagnostic Testing:
- CBC: normal
- Chem 7: normal
- Imaging: an MRI/MRA is done
What is the most likely diagnosis?
- A) Venous sinus thrombosis
- B) Vertebral artery dissection
- C) Stress headache
- D) None of the above
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ANSWER:
- A) Venous sinus thrombosis: The image is of the MR venogram and was read as good quality and normal
- B) Vertebral artery dissection: symptoms are not concerning for this condition
- C) Stress headache
- D) None of the above: CORRECT. On further questioning patient confessed to running out of her SSRI a few days before her symptoms started. She was diagnosed with SSRI withdrawal
1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook
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CASE CONCLUSION: Patient was restarted on her SSRI and told to follow up with her doctor
CASE LESSONS: Always consider medications or their withdrawal as a cause of otherwise unexplained symptoms. Great questions to ask during the initial history include:
- “Are you on any medications?” (I love when this elicits multiple meds after the patient just denied any PMH)
- “Have you started, stopped or changed doses of any medications recently?”