Clinical exam skills: a complicated headache
Ian Bickle, Michael Watt, and Steven McKinstry kick off our new series on typical medical school clinical examination questions
A 26 year old woman was admitted to hospital with headache, double vision, and visual disturbance. She had been on holiday to Spain six weeks previously, and before flying home she had had four days of vomiting from a presumed viral illness. For the next four weeks she had had severe headaches, which were worse on coughing and stooping. These headaches were most apparent first thing in the morning and were only partially relieved by simple analgesics. The double vision was noted in all directions of gaze but was worst when she looked to the left (figs 1 to 5). There is the occasional “spot” (floater) in her vision.
Her past medical history was of recurrent left ear infections as a child. She is on no regular medications and has an intrauterine contraceptive device in situ. On examination her blood pressure was 128/73 mm Hg, blood glucose was 4.9 mmol/l,