Throbbing
Nervous System & Special Senses
0
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M52_F1.jpg"}},{"insert":"\n\n"},{"insert":"Your clinic has been surprisingly light today. Before you realize it, the nurses inform you that all appointments have been processed.\n\nStepping out to the nearby cafe, you savor a delectable Colombian roast coffee, only to be interrupted by a call. Dr. Merkel, the senior dermatologist in your hospital, is on the other end of the line.\n\n\u0022Can I bother you to see a patient of mine? She\u0027s come in with a case of acne, but I feel that she might have a more serious problem.\u0022\n\nIntrigued, you ask him to send her over to the medical clinic right away. Finishing off your coffee quickly, you head back to the hospital.\n"}]}
1
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M52_F2.jpg"}},{"insert":"\n\n"},{"insert":"Caitlyn, a 30-year-old librarian, has had persistent acne for a couple of years now. She\u0027s tried all sorts of over-the-counter creams and lotions and even various diets, but nothing has worked.\n\nWhile she visited Dr. Merkel for help with the acne, what caught his attention was her history of headaches for around two weeks now. These were mild initially but rapidly worsened over time.\n\nThe headaches are generalized, throbbing in nature, and 9\/10 in severity currently. They are present on awakening, exacerbated by coughing and sneezing, and accompanied by nausea, vomiting and pulsatile tinnitus.\n\n\u0022I\u0027ve always had headaches every now and then, but nothing like these last few weeks. Ibuprofen used to help, but now it\u0027s useless,\u0022 Caitlyn says.\n"}]}
2
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M52_F3.jpg"}},{"insert":"\n\n"},{"insert":"You learn that her medical history is only significant for multiple visits to her primary care provider to treat intractable acne. She has recently had course of oral doxycycline. Her menstrual cycles have been irregular for around 2 years and she has been overweight since her teenage years.\n\nHer family history is significant for type 2 diabetes mellitus in both parents. She has had several sexual partners in the past, but has been single for the last 6 months. Caitlyn only drinks socially and does not smoke or use recreational drugs. There is no history of recent interstate or foreign travel, or trauma.\n"}]}
3
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M52_F4.jpg"}},{"insert":"\n\n"},{"insert":"You obtain permission to examine her.\n\nCaitlyn\u0027s BMI is 35 kg\/m2. All vital signs are normal. General examination reveals facial and truncal acne, a Tanner stage of 5, and a Ferriman-Gallwey (mFG) score of 3.\n\nThe cardiorespiratory and abdominal examinations reveal no abnormalities. However, during the neurological examination, you note bilateral grade 1 papilledema. There are no focal neurological signs or features of meningism.\n"}]}
4
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M52_F5.jpg"}},{"insert":"\n\n"},{"insert":"You ask Caitlyn if she\u0027s had any visual disturbances.\n\n\u0022I see just fine, Doctor. I read and drive with no problems. But now that you\u0027ve mentioned it, I\u0027ve experienced a couple of brief episodes of blurriness while driving to work over the last couple of weeks.\u0022\n\nYou realize that Dr. Merkel\u0027s instincts were on spot. Caitlyn definitely needs to be investigated further.\n"}]}
5
{"ops":[{"insert":"What will you do now?\n"}]}
1. Order an MRI brain with venogram and an ophthalmology consult
2. Order an MRI brain with venogram and a lumbar puncture
3. Order an MRI brain with venogram, lumbar puncture, and an ophthalmology consult
8
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7
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6
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