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A 36 year-old woman with a right-sided headache
Case 8
A 36 year-old woman suddenly developed a right-sided headache while sitting on the toilet. The pain
was severe, throbbing, and associated with nausea. She returned to bed and went back to sleep. When
awakened several hours later by her roommate, the patient was drowsy and complained of double vision.
On examination she is sleepy, but easily arousable and oriented, with a stiff neck and incomplete ptosis
of the right eye, which is deviated down and to the right. The right pupil is enlarged at 5 mm and reacts
sluggishly to light.
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies, consultations) would you
obtain? What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? Include doses
for one medication you might prescribe, along with an estimate of the cost of your proposed therapy.
How would you counsel the patient about her condition and about any proposed therapy?
A 36 year-old woman with a right-sided headache
Case 8
A 36 year-old woman suddenly developed a right-sided headache while sitting on the toilet. The pain
was severe, throbbing, and associated with nausea. She returned to bed and went back to sleep. When
awakened several hours later by her roommate, the patient was drowsy and complained of double vision.
On examination she is sleepy, but easily arousable and oriented, with a stiff neck and incomplete ptosis
of the right eye, which is deviated down and to the right. The right pupil is enlarged at 5 mm and reacts
sluggishly to light.
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies, consultations) would you
obtain? What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? Include doses
for one medication you might prescribe, along with an estimate of the cost of your proposed therapy.
How would you counsel the patient about her condition and about any proposed therapy?A 36 year-old woman with a right-sided headache.