Case History #183

Date of Consultation: 2-2-1989

HISTORY OF PRESENT ILLNESS:

This 21-year-old right-handed white male student was referred for neurologic evaluation due to a 10 day history of progressively worsening headache.  The patient was well without prior neurologic problems until 10 days prior to consultation.  At that time, the patient noted the onset of pain in the upper cervical and occipital regions.  Initially, this would only occur when he moved around, held his breath, or strained.  It would usually last for one or two minutes and then subside.  However, over the past 10 days, the duration of the headache became longer and no longer was strictly related to head movements.  He noticed that if he kept his head flexed forward, the pain was somewhat less, but when he extended his head the pain increases.  The quality of the pain was usually a pressure-like sensation but occasionally pulsated.  He experienced nausea and vomiting on one occasion, but he relates that to taking a lot of pain medications.  He also describes some blurriness of vision and impaired balance.  There is no history of head trauma. 

PHYSICAL EXAMINATION:

General examination revealed a healthy young male who was in a lot of discomfort.  He tended to keep his head flexed forward.  However, he was able to move his head and neck in all directions.  There was no neck rigidity, and vital signs were entirely normal without a fever.  Any type of movement seemed to exacerbate the pain. 

NEUROLOGICAL EXAMINATION:

Mental Status Exam:  Intact.

Cranial Nerves:  Sensation of smell was not tested.  Visual acuity and visual field examinations were normal.  Funduscopic examination revealed intact venous pulsations on the left but no spontaneous venous pulsations on the right.  Optic disc margins were sharp on the left but somewhat obscured in the right eye, especially the upper margin of the disc.  External ocular movements were full without nystagmus or diplopia.  Pupils were equal, round, and reactive to light and accommodation.  Sensory and motor functions of the Vth cranial nerve were normal.  There was no facial weakness.  Hearing was intact bilaterally.  XIth cranial nerve functions were normal.  Tongue and palate appeared normal.

Motor System:  There was no evidence of focal or generalized muscular atrophy.  There were no fasciculations.  Muscle tone and power were normal in all 4 limbs. 

Reflexes:  Deep tendon reflexes were symmetric, and the plantar reflexes were flexor bilaterally. 

Sensory System:  All modalities of sensation, including cortical sensations, were normal.

Cerebellar Function:  The patient performed all cerebellar tests normally.

Gait and Stance:  Regular and tandem gait were performed normally, and the Romberg test was negative.

Questions:

1.  Do you think that this patient’s headache problem is due to a serious or structural problem or a more benign process?  Cite the evidence in support of your conclusions. 

2.  How would you characterize or classify this patient’s headache problem? 

3.  What do the findings on funduscopic examination suggest?  What is the significance of these findings? 

4.  Considering this patient’s history and examination, how precisely can the neurologic lesion be localized in this case? 

5.  Indicate the level of the neurologic lesion in this case as precisely as possible and the structures involved by the pathologic process.  If precise localization is not possible, list as many levels or structures as you can that might produce the same clinical picture, if involved by the pathologic process. 

6.  In general, what type of pathologic process do you think is involved in this case?  What other considerations would be in this patient’s differential diagnosis?

7.  What diagnostic procedure(s) would you undertake at this point?