Case+5+-+Headache+and+Neck+Pain

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A 37 y/o female with known HIV reactive status presents on 2/12 with complaint of neck pain and headache accompanied by general weakness and malaise. Patient states that symptoms started last fall with light generalized headaches, however have progressively worsened over the months. Denies any trauma to head or neck. States that headache continues to be generalized and worse when leaning forward. Tylenol and brufen not assisting. The pain is accompanied by persistent neck pain and stiff neck. Since late last summer she endorses weight loss, daily night sweats and fevers. Evidently in last week has had occasional non bloody nonbilious emesis. Denies any cough, diarrhea, chest pain, etc…

Patient was admitted here in late December for similar complaints of headache and neck pain, and LP at that time reported inconclusive (results not known exactly) with negative cryptococcal antigen. Visually the patient as reported to have had a ‘high opening pressure.’ (Opening pressure is not formally measure here on routine basis and instead is occasionally commented on subjectively.) After work-up patient was discharged on tylenol back to ART clinic.

Past Medical History: HIV positive on a second line ART treatment in Malawi (TDF, 3TC, and ATV/r). Was switched from first line regimen (TDF, 3TC, EFZ) after tubercular lymphadenitis 2010. Also with smear positive pulmonary tuberculosis in 2007. Has been adherent with ART clinic visits and compliant with taking ARTs per district wide electronic medical record of all ART patients (6000).

OB Hx: 4 children SVD

Current Medications: ART ‘7A’ regimen (TDF, 3TC, ATV/r)

Social History: widowed in 2014 – husband deceased due to unknown pathology. Currently living with her mother and children (4). Nonsmoker.

PE: Vitals: BP 91 /64 P 102 T36.3 Gen: Cachectic, slow moving, appearing obviously unwell. Speech slow but oriented to person place and time. GCS 15/15. Affect per accompanying guardian flat compared to prior. HEENT: PERRL, no pupil asymmetry. No palpable scalp abnls. No thrush seen intraorally. Neck: Limited active ROM in flexion and extension. Head tilt and neck twist preserved. Passive ROM with stiffness felt in flexion and extension. No LAD. No palpable neck pain; Pulm: CTAB, no crackles or wheezing CV: nl S1 and S2, no m/r/g Abd: soft, nd, nttp, no palpable organomegaly Neuro: CN II – XII intact, no focal findings on thorough exam. Patient with preserved strength and sensation in all extremities. Gait slow but steady, negative rhomberg with normal reflexes.

Labs: Full Blood Count: WBC 6.2, Hgb 9.8, MCV 74.5, Plts 293 CD4: 271 (can be done on the spot in 10 minutes with PIMA machine) ISTAT: Na 141, K 4.5, Cl 104, CO2 28, BUN 11, Creat 0.5, Glucose 83 MRDT: negative (rapid malaria test) Here are the LP results: No overt increased opening pressure Clear in color RBCs: 100 WBCs: 8 No differential on the WBCs given Reagent out of stock for protein, glucose AFB smear: negative Gram stain: none seen Cryptococcal Ag: negative

Chest xray: No overt pulmonary pathology identified: possible area of subtle calcification in RUL perhaps secondary to past pulmonary TB. No granuloma, no infiltrate, and normal sized cardiac silhouette.

//What is your differential for this patient?// //What are your next steps at the district level here in rural sub-saharan Africa?//