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Don't Worry, It's All In Your Head! - Page #1
 

Author: John Evans, DO
Co Author #1: Caleb Curry, DO
Co Author #2: Jennifer Mitchell, MD, FAAFP
Co Author #3: David Edwards, MD
Senior Editor: Kristine Karlson, MD, FAMSSM
Editor: Sarah Szybist, DO

Patient Presentation:
An 18-year-old male presented to the training room with two months of worsening occipital headache and progressive fatigue. A week prior, he visited the physician who diagnosed him with an acute gastrointestinal illness and tension headache, for which he was prescribed Flexeril. He developed dizziness and nausea the day after his first dose of Flexeril. He was seen again and told to stop taking Flexeril; however, his dizziness, nausea, and headache did not improve. During this training room evaluation, he reported worsening symptoms over the last 3 days, which rendered him unable to get out of bed. He reported that he had hit his head on a door frame one month prior to presentation. He denied a history of concussions or experiencing symptoms like this before. Review of systems was negative for weight change, night sweats, fevers, chills, dyspnea, and chest pain.

History:
He reported a single seizure episode at the age of 8 with a normal MRI. He had no pertinent family history and no known drug allergies. He was a Division 1 student athlete and reported no alcohol, drug, or tobacco use. His only medications were over-the-counter vitamin B12 and vitamin D3.

Physical Exam:
On exam, the patient was in no acute distress but appeared fatigued with a blunted affect. His head was normocephalic, and he had tenderness at the base of his occiput; the remainder of his HEENT exam was normal. His abdominal exam was normal. Neurologic testing demonstrated intact cranial nerves, normal sensation and strength in all extremities, and normal patellar, Achilles, biceps, and triceps reflexes. He had an abnormal tandem gait and a positive pronator drift on the left.

Click here to continue. Challenge yourself by writing down a broad differential diagnosis before moving to the next slide.

NOTE: For more information, please contact the AMSSM, 4000 W. 114th Street, Suite 100, Leawood, KS 66211 (913) 327-1415.
 

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Phone: 913.327.1415


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