Agreed, likely MRI.
Dr. Todd Zimmerman
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From: Scarfone, Richard <[log in to unmask]>
To: PED-EM-L <[log in to unmask]>
Sent: Sat, Nov 3, 2012 4:11 pm
Subject: Re: Teenager with two days of headache
Thanks for sharing this case.
he differential is fairly broad here in a child with intermittent headaches for
weeks. and includes pseudotumor cerebri, migraine, post-concussive, tumor,
tc. Given the duration of symptoms, an acute bleed seems less likely. Also,
espite the photophobia, from what you describe, meningitis seems unlikely- yet
"low-grade" meningitis (as might be seen with Lyme) is possible. Any recent
ick bites, EM rash? Does he live in or did he travel to a Lyme endemic region?
Regarding pseudotumor cerebri: does he have any risk factors and did he have
apilledema on exam?
egarding migraines: does he have an aura or associated nausea/vomiting, is the
eadache focal, and is there a family history?
egarding post-concussive: does he have other associated signs/symptoms such as
atigue, poor memory, insomnia, etc.
Regarding need for admission: will largely depend on his degree of discomfort.
n a scale of 1-10, what degree of pain does he report?
An aggressive approach in the ED would be an emergent CT, followed by an LP with
pening pressure. I would certainly go this route if he has papilledema. Without
apilledema and assuming he has a low degree of pain, an MRI would be preferable
o avoid the radiation associated with a head CT, even if it had to wait until
he following day.
rom: Pediatric Emergency Medicine Discussion List [[log in to unmask]]
n behalf of Lakshmi Vemuru [[log in to unmask]]
ent: Saturday, November 03, 2012 4:25 PM
o: [log in to unmask]
ubject: Teenager with two days of headache
A 15 year old male presented with headache for 2 days with associated
hotophobia, nausea but no vomitings. Past
history of head to head collision while playing football 6 weeks ago.
o LOC, no dizziness but had mild headache. Assessed by trainer
t that time and cleared. Went to PCP two days later diagnosed with possible
for sports after 2 weeks. Interval history of occasional mild
eadaches otherwise no complaints and continued to play football. Seen
y PCP day prior to our ED visit because of headache and photophobia.
iagnosed with migranes and prescribed NSAIDs. Presented to our ER
ecause of persistent headache.
Alert oriented X3 pupils equal
eactive. Vitals afebrile, RR16, BP 132/68, HR 98 oxygen sat 98%.
hysical exam no signs of external injuries, clear breath sounds,
ormal heart sounds. No orthostatic changes. No focal neurological
igns but complains of dull headache and photosensitivity. Mild nausea
omiting episodes. IV fluids, toradol, and zofran given with
inimal improvement. Continued to watch TV and interacting with family
ut requested to keep lights off. But no change in vital signs and
emained stable with no cardiorespiratory distress
Questions to the group:
1)With this history and physical exam how will you proceed further in this
) At this time would you do CT scan head or not ?
) Any votes for MRI?
) Admission for pain management?
) Consult Neurologist and wait to hear from him?
akshmi Vemuru M.D; FAAP
oledo Children's Hospital, OH
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