Neurology

Randolph W. Evans, MD, chief of neurology at Park Plaza Hospital and clinical professor at Baylor College of Medicine in Houston, Texas, reviews postconcussion syndrome and post-traumatic headache.

Anxiety disorders are as prevalent and disabling as depression; they affect about 19.1 million adults in the United States at some point during their lifetimes.1-3 Because of the high suicide risk associated with depression, patients who have anxiety may attract less attention from their primary care providers. Thus, anxiety disorders often go undiagnosed and untreated.

A 51-year-old man was hospitalized for subacute alteration of mental status. The patient had a history of alcohol abuse. He had no other medical disorders. Vital signs were normal. The patient scored 15 out of 30 on the Mini-Mental State Examination. He had an ataxic gait; all other physical findings were normal. The family reported that he had been treated in the emergency department 3 days earlier for hypoglycemia. Results of a complete metabolic profile and complete blood cell count were normal.

A 22-year-old man seeks medical attention at his college’s infirmary. He had been in excellent health until 1 week earlier, when he noted onset of fever, headache, and malaise.

The patient has a small-fiber sensory neuropathy that is managed with lamotrigine. She is a physical therapy student who has frequent patient contact. She drinks alcohol occasionally but denies smoking and illicit drug use; she says she is not sexually active.

A 47-year-old Hispanic woman with severe headaches of 1 month’s duration presents to the emergency department (ED). The pain encompasses the entire head, is constant and crushing (10 on a scale of 1 to 10), and has progressively worsened.

Two weeks before admission, he had visited the emergency department (ED) because of the headache. Migraine was diagnosed and ibuprofen had been prescribed. The headache persisted despite NSAID therapy, and the patient returned to the ED 2 days later.

A previously healthy 16-year-old boy presents for evaluation of a slightly pruritic, nontender, generalized rash.

Six days ago, a 36-year-old man had noticed a dark spot in the field of vision of his left eye. Now the spot more closely resembled a line. He denied other changes in his vision and had not seen any floaters or flashing lights.

A 14-year-old boy presents with frequent severe headaches characterized by sharp, throbbing pain behind his left eye and left temple.

A 28-year-old woman presents with milky discharge in both breasts and throbbing occipital headaches of 4 months' duration. The headaches begin gradually, do not radiate, and have no apparent triggers or relieving factors.

I have read both that the male brain has no estrogen receptors and that testosterone is converted to estrogen in the brain. Where does the truth lie? And what role, if any, does estrogen play in preventing Alzheimer disease in both men and women?

Depression was diagnosed 6 years earlier in a 37-year-old woman; it has been successfully managed since then with fluoxetine and outpatient psychotherapy. Since her teenage years, the patient has also experienced sporadic (fewer than 3 or 4 per year) mild or occasionally severe headaches, which she has usually self-treated with over-thecounter (OTC) agents or "just slept off."

The development of more sophisticated testing modalities now permits the identification of coronary artery narrowing in asymptomatic adults. The images obtained in these studies provide potential targets for intervention-based therapy.

A 47-year-old woman complains of severe headaches that involve only the right orbital, temporal, and occipital areas. She describes the pain as sharp and stabbing, and she rates its severity as 9 or 10 on a 10-point visual analog scale.

LONDON -- Headache patients receiving prophylactic high-dose verapamil face a risk of heart rhythm disturbances that warrants EKG monitoring of all patients on the therapy, investigators here concluded.

A 50-year-old man with end-stage renal disease secondary to long-standing hypertension had an elevated hematocrit and progressively increasing hemoglobin levels. For the past 7 years, he had been receiving hemodialysis 3 times a week. He denied headache, flushing, easy bruising, bleeding, nausea, vomiting, chest pain, dyspnea, and other symptoms. He was not receiving exogenous erythropoietin.

The headaches vary in severity, but she usually has severeheadaches (8 on a 10-point visual analog scale[VAS]) once or twice a week; she describes the latter assevere throbbing or pounding pain on the top of thehead but also involving the occipital and frontalareas and occasionally one or the other temple.

A 24-year-old woman presents to the emergency department (ED) withgeneralized weakness, headache, and muscle cramping that have progressivelyworsened over the past week. Recently, she has also had nauseaand vomiting. She denies chest pain, palpitations, dyspnea, cough, fever,chills, diarrhea, and urinary symptoms. She has a history of type 1 renaltubular acidosis.

In his "What's Your Diagnosis?" case of an 89-year-old woman with advanced Alzheimer disease who had injuries attributed to a fall in a nursing home (CONSULTANT, October 2006, page 1373), Dr Henry Schneiderman notes that "the fall was not observed" and that "many prior falls have been ascribed to her lack of safety awareness in negotiating the environment."

TOLEDO, Ohio -- Migraine sufferers often have more than a headache, according to investigators here.

A 47-year-old woman complains ofepisodic headaches that began severalmonths earlier and are accompaniedby sweating, flushing, abdominal pain,and vomiting; these attacks have progressivelyworsened. She takes no medicationsand denies fever, chills, andnight sweats. The medical history isunrevealing.

For 3 months, a 66-year-old retired man has had increasingweakness of the lower legs with stiffness,tingling, and numbness; worsening ataxia; anergia; andexertional dyspnea of insidious onset. He has lost 8 lb,and his appetite is poor. He denies fever, cough, chest orabdominal pain, paroxysmal nocturnal dyspnea, orthopnea,ankle swelling, bleeding disorders, hematemesis,melena, headache, vision problems, sciatica, joint pain,bladder or bowel dysfunction, and GI symptoms. He hasnocturia attributable to benign prostatic hypertrophy.

A 78-year-old widower with hypertension, type 2 diabetes, and hyperlipidemiais referred for a comprehensive geriatric assessment.His daughter is concerned about her father’s decline following her mother’s death a year ago.His memory seems to be deteriorating. His desk is cluttered with bills, but he refuses to lethis daughter help him or even look at his checkbook.

For the past week, a 16-year-old boy has had a progressively worsening dry, irritating cough; dyspnea on exertion; and intermittent fever and chills. During the past 24 hours, he has had no appetite and has vomited greenish material 3 or 4 times.

A 30-year-old woman complains that her headaches no longer respond to triptans; instead, they have increased in frequencyand severity. The pain interferes with her ability to work part-time and to take care of her 16-month-old daughter.

A 46-year-old man presents with right-sided facial paralysis. His symptoms beganthe previous evening when he had difficulty in closing his right eye; by morning,paralysis had developed. He also reports headache and mild photophobia.

We chose to present this case to readersbecause the patient’s neurologicexamination was normal and her presentationthus appeared benign.

What is the risk of dementia in patients who have had an ischemic stroke?

A 23-year-old man presents to the emergency department with fever, headache,and photophobia. His illness began 5 days earlier with malaise, followed byfever, prostration, nausea, and vomiting. After 3 days, a severe headache developed,accompanied by photophobia; the headache did not respond to over-thecounteranalgesics.