Triage: Headache and blurry vision for two days.  No fever or vomiting.

History of Present Illness: A 35-year-old female presents with 2 days gradual onset posterior headache which is a little bit more severe on the right side.  She reports severe nausea, as well as shakiness and on/off blurred vision but no vomiting, focal weakness, numbness, changes in balance or other complaints.

Vital Signs: Vital signs are normal except for a heart rate persistently elevated in the 110-120 range.

Physical Exam: Other than tachycardia, the physical exam is otherwise normal including no photophobia, meningismus or focal neuro findings

What diagnostic testing should you order? (may select more than one)

  1. Influenza swab
  2. Head CT
  3. Urinalysis
  4. Chem 7 & CBC

SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT

 

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ANSWERS: 

  1. Influenza swab – good idea
  2. Head CT – not indicated
  3. Urinalysis – CORRECT – pyelonephritis can present with headache and tachycardia but no dysuria, flank pain or fever.
  4. Chem 7 & CBC – CORRECT – anemia and hyponatremia can both present with headache

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CASE CONCLUSION:: viral swab negative but UA showed 100 WBC with clumps and rare bacteria.  It eventually grew >100K E. coli.  Sent home on antibiotics.  Urine culture positive.  Headache gradually resolved over next 3-4 days

CASE LESSONS:

  1. Pyelonephritis is not typically considered a cause of isolated headache, but occasionally it can be.  Often is such cases there will also be fever and even vomiting but no flank pain, such that it mimics meningitis, but as this case demonstrates pyelo can present as headache alone without other symptoms.