1. Case 3 Headache & Slurred Speech Case Presentation
Clinical Pathologic Case Conference
The Fifth Mediterranean Emergency Medicine Congress
Valencia, Spain
September 16, 2009

2. Chief Complaints
Headache
Slurred Speech

3. History of Present Illness
52 year old African American male, 2 weeks ago
went to a cookout, then complained of:
constipation
nausea & vomiting
low grade fever

4. ED visit #1 Headache & neck pain  local ED 2 days later:
Negative abdominal xray
phenergan and miralax
improvement in his symptoms

5. ED visit #2 3 days later Food stuck in his throat Negative head CT
New symptoms:
Food stuck in his throat
Painful swallowing
Workup at that time:
Negative head CT
GI Referral

6. GI referral Upper endoscopy revealed: Duodenal inflammation
Patient was prescribed:
Carafate
Omeprazole

7. Intermittent Symptoms:
ED visit #3 2 weeks later
Intermittent Symptoms:
headaches & neck pain
fevers
dizziness
nausea & vomiting
dysphagia
New Symptoms:
slowed & slurred speech
transient right arm weakness
balance problems

8. Headache
diffuse
right-sided
right neck pain
photophobia

9. Review of Systems urinary hesitancy itchiness and rash
about one week ago
right calf
resolved

10. Past Medical History
HTN
GERD
BPH
h/o Cat Scratch disease

11. Social History no sick contacts remote tobacco social alcohol
no travel history

12. Family History
No history of:
CVA/TIA
TIA
HTN DM
CAD

13. Physical Exam
General: Afican American male lying on right side in bed in discomfort from headache pain
Vitals: Temp 36.8C (98.2F), BP 131/91, Pulse 89, Resp 18, O2 Sat 99% RA
HEENT: PERRLA, EOMI, conjunctiva clear
Neck: supple and non-tender, no lymphadenopathy
Pulmonary: clear to auscultation bilaterally
Cardiovascular: RRR, no murmurs, rubs, or gallops
Abdomen: normal BS, soft, non-tender, no masses
Extremities: good pulses x 4, no edema, tenderness, or swelling

14. Neurological Exam Alert & oriented Normal speech, motor, reflexes
Decreased sensation to pinprick on right CN V2-V3, R upper extremity & R lower extremity
Dysmetria with finger-to-nose and heel-to-shin on the right
Slow & wide based gait

15. Laboratory Data Complete Blood Count Our patient Normal values
WBC
Hemoglobin
Hematocrit
Platelets 15

16. Laboratory Data (cont)
Metabolic Panel
Our patient Normal values
Sodium
Potassium
Chloride
Carbon dioxide
Blood urea nitrogen
Creatinine
Glucose
Calcium
Phosphorus 16

17. Laboratory Data (cont)
PT 12.6 sec sec
PTT sec sec
INR 1.1 sec sec 17

18. EKG

19. Head CT

20. Summary 52 year old previously healthy man with
intermittent right-sided headaches and neck pain
dizziness, nausea and vomiting
transient right-sided weakness/decreased sensation
gait difficulties and ataxia
dysphagia and dysarthria
negative head CT
And now Dr. Freeman will provide us with a discussion of the case

21. A diagnostic procedure was performed…