Triage: Headache for 3 weeks

History of Present Illness: A man in his mid-30’s with a history of HTN and of acne for which he takes Accutane, presents to the ER with 3-4 weeks of generalized headache that has been getting progressively worse.  He recently started to develop bilateral eye pain.  He denies any fever, chills, vomiting, change in visual acuity or focal neurologic symptoms.

Vital Signs: Vital signs are normal.

Physical Exam: On exam he has mild photophobia and a positive jolt sign, but a non-focal neurologic exam.  His abdomen is non-tender but obese.

Labs: CBC and BMP were normal

 

What additional testing is indicated?

  • A) None
  • B) Drug screen
  • C) CT brain
  • D) Lumbar puncture

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What additional testing is indicated?

  • A) None
  • B) Drug screen
  • C) CT brain
  • D) Lumbar puncture – CORRECT

 

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CASE CONCLUSION: LP showed 2 WBC but opening pressure was 34.  He had 10ml of fluid removed and closing pressure was 25.  He was discharged home on Diamox for pseudotumor with close follow-up with both ophthalmology and neurology.  He was also urged to lose weight and discontinue Accutane as both are risk factors for IIH (Idiopathic Intracranial Hypertension)

CASE LESSONS:

    • Check opening pressure on an LP especially with a history of progressive headache for weeks in a patient with risk factors for pseudotumor (IIH)