A 33-year-old woman has been experiencing recurrent episodes of nausea, headaches, and dizziness for the past 8 months. She has come to the emergency department because she is concerned about her current episode, which is slightly different from her previous ones.
Her symptoms began in the early morning, waking her from sleep at around 5 AM. She had head pain, dizziness, and nausea—similar to the previous episodes—yet she has noticed flashing lights in front of her eyes. She also complains of tingling in both arms and hands, which had occurred with a few of her earlier bouts. She has been taking over-the-counter ibuprofen and acetaminophen all day long without improvement. She went to work as usual and has been trying to sleep since returning home from her job. However, she has been unable to sleep due to the pain.
She has been previously healthy. She has been taking oral contraceptives for birth control for the past 7 years. She has not recently had any changes to her oral contraceptive prescription. She has a normal menstrual cycle and has experienced monthly menstrual migraines for the past 5 years. They always improve with one or two doses of sumatriptan.
The recurrent headaches began about 8 months ago. They have been occurring about once a week and lasting between 24 to 48 hours. She has taken sumatriptan for her headaches, and, like her menstrual migraines, they improve with one or two doses.
She has a family history of inflammatory bowel disease, and when she began to experience intermittent abdominal discomfort a few years ago, she decided to become a vegetarian. She explains that she has been getting enough calories and protein intake since the switch in diet about a year ago.
The patient was afebrile, well-nourished, and healthy appearing. She had both a severe headache and nausea. She complained of dizziness, but the dizziness does not interfere with her ability to walk. She felt the urge to vomit several times during the evaluation, but instead of vomiting large amounts, she gags.
The skin appeared normal, with no bruises or rashes. Throat examination was normal, as was thyroid examination. The chest examination was normal, with clear breath sounds. Her cardiac examination reveals a regular heart rate and rhythm. Pulse were palpable and normal in bilateral upper and lower extremities. Her carotid arteries were normal with no bruits. Abdominal exam was normal, with no pain, tenderness or masses.
The patient was alert and oriented x3. Her speech was normal. Extra ocular movements were intact with no nystagmus, and her vision was normal. Pupils were equal, round ,and reactive to light. She did not have ptosis or facial asymmetry. She had photophobia. Facial sensation and movements were normal bilaterally.
She had normal strength in the bilateral upper lower extremities. Reflexes were slightly brisk in bilateral upper and lower extremities, with no asymmetry. Sensation was normal in bilateral upper and lower extremities to touch, pinprick, vibration, and position sense. She had no ataxia or dysmetria in bilateral upper and lower extremities. Gait was normal and she could perform a Romberg test and heel to toe walking without any difficulty.
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