A 35-year-old Asian man presents to the emergency department with a severe headache. He states he rarely gets headaches, but has been having them on and off all week, all mild to moderate until tonight, when right after sexual intercourse, he experienced a sudden severe headache and vomited twice. He denies having had any fever, neck stiffness, or changes in strength, coordination, speech, or vision and has no other complaints.
He denies any past medical history or drug use. There is no family history of aneurysm or migraine but his mother is a dialysis patient.
On examination his vital signs are normal and he appears to be in mild distress. You think his neck may be a little stiff, but he can bend his chin to his chest. The rest of his examination, including a full neurologic examination, is normal.
Labs are normal except for a sodium level of 132 mEq/L and a creatinine of 1.6 mg/dL. A CT scan of the brain is ordered and read by the radiologist as normal (Figure 1); you then recommend a lumbar puncture (LP), but the patient refuses despite all the terrible things you tell him may happen if he has an aneurysm or meningitis. He goes on to state that he has been using his smart phone to research headaches and thinks he has a “post-coital headache,” which he read is not dangerous.
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