Headache 355341.A 78-year-old man presents to triage of your ED complaining of
gradual onset of headache over the course of the day. The headache is
present almost everyday and wonders if it is related to the unusually cold
temperatures this winter. He describes the headache as bounding and con-
stant. You notice that his face is very ruddy in appearance. He is afebrile but
looks rather lethargic and seems somewhat short of breath. He is afebrile
and saturating 100% on pulse oximetry. One of your coworkers informs you
that the patient’s wife is in another part of the emergency room with a simi-
lar presentation. Two more ambulances arrive, one with a patient complain-
ing of a similar headache and another with a patient who is obtunded. All
live in the same building. What is the next most appropriate step in the man-
agement of these patients?
a. Place the patient in respiratory isolation for presumed Neisseria meningitidis
infection.
b. Draw a blood gas and send it for cooximetry.
c. Start antibiotic therapy and perform an LP.
d. Treatment for migraine with triptans or IV antiemetics.
e. Transfer of all three patients to the nearest hyperbaric facility.
342.A 35-year-old man presents to the ED complaining of a headache
over the previous 4 weeks. He was assaulted with a bat 4 weeks ago and
was admitted to the hospital for observation in the setting of a small trau-
matic subdural hematoma. Repeat noncontrast CT scan of the head 2 weeks
ago was normal with resolution of the hematoma. He states he has
headaches several times each day. They last from 5 minutes to several hours.
They are sometimes band-like, other times they are localized to the site
where he was struck. They can be pulsating or constant and are associated
with sensitivity to sound. A head CT scan today is normal. Which of the fol-
lowing is the most likely diagnosis?
a. Postconcussive syndrome
b. Posttraumatic hydrocephalus
c. Subdural hygroma
d. Cluster headache
e. Posttraumatic stress disorder