Physical Examination

Some potential diagnoses you should consider are meningitis, venous thrombosis, arterial dissection, migraine headache, subarachnoid hemorrhage, meningioma and spontaneous intracranial hypotension.

Age:                    55 yrs.

Height:                64 in.

Weight:               164 lbs.

Temp:                 98.2 F

Pulse:                 96 regular, smooth, symmetrical

BP:                     142/88

The patient is in obvious distress and immediately asks if she can lie down. Evaluation of the head and neck reveals no lymphadenopathy or thyromegaly. There is general muscle tenderness but no pronounced pain. The cranial nerve exam is unremarkable with the exception of eye movement which demonstrates a bilateral failure to look upwards. While there is no obvious cognitive deficit, the patient seems unfocused. Cerebellar testing (graphesthesia, stereognosis, Diadochokinesis, finger to nose) are intact. The patient’s gait is slow but even and symmetrical. All cervical active and passive ranges of motion are unrestricted, however, the patient is apprehensive about performing flexion and extension since this exacerbates the headache.

Question: What is your working diagnosis at this point?

Question: What imaging or laboratory studies would you order?