Case Presentation
A 56-year-old woman presented to the emergency department with a 1-week history of frontotemporal headaches and nausea. She also noted mild upper respiratory symptoms and cough, which she had treated with codeine. When her headaches had progressed to what she described as “the worst pain in her life” and she began to vomit, she decided to go to the emergency department.
The patient reported no fevers, stiff neck, or focal neurologic symptoms and had no history of recent travel or known sick contacts.
Patient’s File History
Medications: None
Allergies: No known allergies to medications
Medical History
Mild intermittent asthma
Allergic rhinitis triggered by mold
Menopause at 53 years of age
Social History
Lives in New England; born and raised in the United States
Is married and has two daughters and one son
Has never smoked
Drinks alcohol occasionally; no history of illicit drug use
Is retired from job as business executive
Family History
Has two siblings; sister has a history of histoplasmosis,
brother has no clinically significant medical history
Father has hearing loss; mother has rheumatic heart disease
Paternal grandmother has diabetes mellitus
Physical Examination
Vital Signs and General Appearance
Temperature, 36.6°C
Pulse, 62 beats per minute
Blood pressure, 103/54 mm Hg
Respiratory rate, 16 breaths per minute
Oxygen saturation, 94% while breathing ambient air
Awake and in mild distress
Skin and musculoskeletal system
Normal skin turgor with no evidence of tenting
No rashes
No jaundice
Nontender, nonswollen joints, with normal range of motion
No edema in legs or feet
Nervous system
Cranial nerves II–XII intact
Superior bitemporal visual-field defect
No papilledema
Symmetric and full strength and sensation in both arms and in both legs
Reflexes appropriate throughout
Gait normal
Head and neck
Sclera anicteric, no photophobia
Pupils equal in size, round, and reactive to light
Clear pharynx without lesions or ulcers
No sinus tenderness
Moist mucous membranes
No palpable thyromegaly
No cervical adenopathy
No jugular venous distention
Chest, heart, and lungs
Heart sounds regular, with no murmurs, rubs, or gallops
Breathing comfortable
Lung sounds clear and symmetric
Abdomen
Bowel sounds present
Nontender in all four quadrants
No appreciable organomegaly
Laboratory Results
Hematocrit (%)35 (36.0–48.0)
White-cell count (per mm3) 4970 (4000–10,900)
Absolute neutrophil count (per mm3)2660 (1920–7600)
Absolute lymphocyte count (per mm3)1710 (720–4100)
Absolute monocyte count (per mm3)520 (160–1100)
Absolute eosinophil count (per mm3)60 (0–500)
Absolute basophil count (per mm3)10 (0–150)
Erythrocyte sedimentation rate (mm/hr)17 (0–18)
Platelet count (per mm3)258,000 (150,000–450,000)
Sodium (mmol/liter)118 (136–145)
Potassium (mmol/liter)3.6 (3.4–5.0)
Chloride (mmol/liter)80 (98–107)
Bicarbonate (mmol/liter)21 (22–31)
Urea nitrogen (mg/dl)10 (6–23)
Creatinine (mg/dl)0.5 (0.5–1.2)
Glucose (mg/dl)88 (70–100)
Calcium (mg/dl)9.1 (8.8–10.7)
Phosphorus (mg/dl)3.1 (2.4–4.3)
Magnesium (mg/dl)1.61.7–2.6Low
Serum osmolality (mOsm/kg water)251 (280–296)
Urine osmolality (mOsm/kg water)526 (150–1150)
Urine sodium (mmol/liter)85
C-reactive protein (mg/liter) <0.50–3
Question 2
Question 3
Case 2
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