Headache and Neck Pain – OSCE Case

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Introduction

A 23-year-old woman attends the emergency department with a headache and neck pain. Work through the case to reach a diagnosis.

UK Medical Licensing Assessment (UKMLA)

This clinical case maps to the following UKMLA presentations:

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History

Presenting complaint

“I’ve had this awful headache and just can’t get rid of it, and my neck is really sore too”

History of presenting complaint

When did the headache start?Β 

“About 4 days ago”

What were you doing when it started?

β€œJust going about my day really, I can’t think of anything that set it off specifically”

Where do you feel the headache?

β€œIt started at the back of my head but now I feel it throughout”

Can you describe the pain?

β€œThrobbing”

Does the pain travel or radiate anywhere?

β€œDown the back of my head to my neck”

Has the pain changed since it started?

β€œYes, it has been progressively worsening”

Does anything relieve the headache?

β€œLying down in a quiet room with the lights off”

Does anything worsen it?

β€œBright lights, loud sounds”

On a scale of 1 to 10, 10 being the worst, how severe is the pain?

β€œ5/10 at the moment”

Did you hit your head or suffer a head injury?

β€œNo”

Have you taken any medication?

β€œParacetamol, but it didn’t do much”

There are several red flag features that are important to ask about when taking a headache history:

Do you have a fever?

β€œI’ve had a fever of 38.4oC”

Do you feel confused or disorientated?

β€œMy brain feels foggy”

Do you have any nausea, or have you vomited?

β€œI vomited once this morning”

How is your appetite?

β€œI have no appetite”

Have you had any changes to your eyesight?

β€œI feel a pressure in my eyes and bright lights bother me”

Have you had any changes to your hearing?

β€œI am very sensitive to loud noises”

Is anyone else at home feeling sick?

β€œI live with 6 housemates who are all nursing students. All are well”

Does anyone else have similar symptoms to you?

β€œNo”

Have you been around anyone else who is unwell?

β€œI have placement in hospitals and I have been working with sick children for the last 3 weeks”


Clinical examination

Examination findings

  • HR 118, RR 18, BP 102/54, Oxygen saturations 95% on air, Temperature 38.6oC
  • GCS 14/15 (E4V4M6)
  • No focal neurological deficit
  • Pupils equal and reactive to light, 3mm
  • Reflexes intact
  • Normal tone
  • Prolonged capillary refill time (>2 secs)
  • Heart sounds normal
  • Rash on lower limbs

Lower limb rash

While examining the patient, you find the rash shown below.

Figure 1. Rash seen on the patient’s lower limbs.1

Non-blanching petechiae or purpura


Investigations

Contraindications to LP include:

  • Suspicion of raised intracranial pressure
  • Anticoagulant therapy
  • Thrombocytopaenia or other clotting disorders
  • Suspicion of a spinal abscess
  • Risk of herniation (i.e. Arnold-Chiari malformation)
  • Acute spinal cord trauma
  • Congenital spinal abnormalities

In these circumstances, imaging with CT or MRI should happen before considering lumbar puncture.


Diagnosis

  • Meningitis: fever, headache, non-blanching rash, photophobia, and phonophobia are all highly suggest meningitis.
  • Encephalitis: although this patient is disoriented, there are no features suggestive of impaired brain function (personality changes, behavioural changes, impaired speech).Β 
  • Cerebral abscess: this patient has no known risk factors (HIV, immunosuppression, traumatic head injury, chronic sinusitis) and has no focal neurological symptoms, so a cerebral abscess is less likely
  • Tick-borne infection (Lyme disease): there is a reduced likelihood of tick-borne infection as she has no known exposure to wooded areas
  • Influenza or other viral illness: symptoms are more suggestive of CNS infection
  • CNS malignancy: the acute nature of symptoms is more suggestive of an infective aetiology

Lumbar puncture results

The results of the patient’s LP are as follows:

  • Appearance: Turbid
  • Protein: 300 mg/dL (Elevated)
  • Glucose: 1.5 mmol /L (Low)
  • Glucose CSF: Serum ratio: 0.40 (Low)
  • WCC: 1.5 x 10^9/L (High)
  • Cell predominance: Neutrophils

Bacterial meningitis. The most common organisms in this age group as neisseria meningitidis, streptococcus pneumoniae, and haemophilus influenzae type B.


Management

This patient should be managed as a potential sepsis patient, and the sepsis six should be started (IV fluids, oxygen if required, and empiric antibiotics). They should also receive antipyretics, analgesia, and nutrition support if needed.

For confirmed meningococcal cases, prophylactic antibiotics are indicated for close contacts (e.g. housemates) within 24 hours (usually ciprofloxacin or rifampicin).


Complications

Hearing loss is the most common complication seen in survivors of acute bacterial meningitis. Other complications include seizures, motor deficits, cognitive impairment, hydrocephalus, and visual disturbances.


Editor

Dr Jess Speller


References

  1. DrFO.Jr.Tn. Petechial rash. License: [CC BY-SA 3.0].Β 
  2. NICE CKS.Β Meningitis – bacterial meningitis and meningococcal disease.Β Updated July 2019. Available from: [LINK]
  3. Van de Beek et al.Β Clinical features and prognostic factors in adults with bacterial meningitis. March 2005. Available from: [LINK]
  4. Patient.info.Β Lumbar Puncture. Updated October 2015. Available from: [LINK]

 

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