100 Cases in Clinical Medicine

CASE 76: HEADACHE

History

A 24-year-old man presents to an emergency department complaining of a severe
headache. The headache started 24 h previously and has rapidly become more intense. He
describes the headache as generalized in his head. He has vomited twice and appears to be
developing drowsiness and confusion. He finds bright lights uncomfortable. There is no
significant previous medical history or history of allergy. He smokes 10 cigarettes per day
and drinks 24 units of alcohol per week. He is not taking any medication currently. He is
a graduate student doing an MA in psychology. He lives with his female partner and they
have two children aged 3 and 4 years.

Examination

He looks flushed and unwell. His temperature is 39.2°C. He has stiffness on passive flexion
of his neck. There is no rash. His sinuses are not tender and his eardrums appear normal.
His pulse rate is 120/min and blood pressure 98/74 mmHg. Examination of heart, chest and
abdomen are normal. His conscious level is decreased but he is rousable to command and
there are no focal neurological signs. His fundi are normal.

Normal

Haemoglobin 13.9 g/dL 13.7–17.7 g/dL

White cell count 17.4% 109 /L 3.9–10.6% 109 /L

Platelets 322 % 109 /L 150–440% 109 /L

Sodium 131 mmol/L 135–145 mmol/L

Potassium 3.9 mmol/L 3.5–5.0 mmol/L

Urea 10.4 mmol/L 2.5–6.7 mmol/L

Creatinine 176 &mol/L 70–120&mol/L

Glucose 5.4 mmol/L 4.0–6.0 mmol/L

Blood cultures results awaited

Chest X-ray: normal

Electrocardiogram (ECG): sinus tachycardia

Computed tomography (CT) of brain: normal

Lumbar puncture turbid cerebrospinal fluid (CSF)

Leucocytes #8000/mL !5/mL

CSF protein 1.4 g/L !0.4 g/L

CSF glucose 0.8 mmol/L #70 per cent

plasma glucose

Gram stain: result awaited

INVESTIGATIONS

Questions

• What is the diagnosis?


• What are the major differential diagnoses?


• How would you manage this patient?