Not tonight, Dear

Diagnostic Challenge

CJEM 2001;3(2):153

A22-year-old man presented to the emergency department complaining of a headache that had developed gradually one week earlier and worsened steadily. He described it as a constant bi-frontal pressure that radiated to the top of his head. It was 9/10 in severity, worse with activity and unrelieved by over-the-counter analgesics. He denied photophobia, phonophobia, neurological symptoms, nausea, vomiting, fever, neck stiffness, trauma or visual disturbances. Review of systems was positive for a mild sore throat and clear nasal discharge. The past medical history was unremarkable, and he had no history of prior headaches. He took no medications, had no allergies, did not smoke. He drank alcohol only on social occasions.

 
Fig. 1. Results of computed tomographic scan of the head.

Examination revealed an alert man in moderate discomfort. His temperature was 36.6°C, heart rate 88 beats/min, blood pressure 130/90 mm Hg, and respiratory rate 12 breaths/min. Physical examination was otherwise unremarkable; there were no signs of head or neck trauma and no meningismus. Examination of the ears, eyes, nose and throat was normal. Hematology revealed a white blood cell count of 8.9 g/L.

The patient was treated with a 1-L bolus of normal saline followed by 10 mg of stemetil, administered intravenously. One hour later, a repeat dose of stemetil was given; there was no improvement in symptoms. As a result, a CT scan of the head was ordered (Fig. 1). Based on the CT findings, the most appropriate next step is:

the answer to this Challenge

© Dr. Vince T. Cheng