It had been a typically busy Monday on acute medical take and the referrals just kept coming. “I’ve got another one for you”, the A&E F2 said, “a 26-year-old woman presenting with headache and neurological symptoms. I’ve discussed the case with my registrar and we feel she needs admitting to exclude a subarachnoid haemorrhage”.

Due to the 4-hour target she was whisked straight out of A&E and up to the Acute Medical Unit for further assessment. Lisa had been in her local supermarket with a friend when she suddenly felt light-headed and dizzy. Her symptoms were associated with a headache. She described the headache as a generalised pressure which was severe enough for her to sit down, as at one point she felt she was going to faint. Her vision had become blurred and her friend reported that her speech had been slurred. Differential Diagnosis Of Acute New Headache
 
She felt much better since arriving at hospital and apart from a persistent mild headache and some tingling in her hands (paraesthesia ) she felt fine. “I feel like I’m wasting your time”, she laughed nervously. Systemic and neurological examination was normal. Routine bloods had already been sent including a renal profile which came back showing a low serum bicarbonate level of 18. This got the alarm bells ringing. Arterial Blood Gas Basics


Something just didn’t add up and despite the pulse oximeter showing normal haemoglobin saturations of 99% on room air I proceeded to do an arterial blood gas from the radial artery.Taking An Arterial Blood Sample

 Lisa_ABG.png


She had a primary respiratory alkalosis with mild metabolic compensation. I went back to take a more complete history from Lisa with the causes of respiratory alkalosis in mind.Causes Of Respiratory Alkalosis

She was not taking any medications and her caffeine intake was low. Systemically she was well with no evidence of lung disease, fever, or meningitis.Hyperventilation And Hypoventilation

She then divulged that she had experienced a similar milder episode afew days ago when on a train. She was concerned that there was something seriously wrong. She wasn’t sleeping or eating well and felt exhausted all the time. She had recently broken up with herboyfriend and was finding work very stressful and had taken a significant amount of sick leave as she often felt light-headed and faint. She had become increasingly isolated from her friends. Neural Control Of Breathing

I felt Lisa was exhibiting psychological and biological symptoms of depression and on direct questioning she admitted to feeling depressed. The headache, paraesthesia and respiratory alkalosis could be explained by hyperventilation caused by anxiety and stress. I explained this to Lisa and she was relieved by the diagnosis. Symptoms Of Hyperventilation

I carefully outlined the case to the medical registrar on call, who agreed with my assessment. She still felt that a CT head and lumbar puncture were warranted in view of the persistent headache, but I worried about the risks of both procedures. We discussed the risk of missing a SAH diagnosis.

Several hours later, we were reassured that the CT head and LP were normal.

We had Lisa discharged and advised to see her GP for further management of her depression and anxiety.

It had been a typically busy Monday on acute medical take and the referrals just kept coming. “I’ve got another one for you”, the A&E F2 said, “a 26-year-old woman presenting with headache and neurological symptoms. I’ve discussed the case with my registrar and we feel she needs admitting to exclude a subarachnoid haemorrhage”.

Due to the 4-hour target she was whisked straight out of A&E and up to the Acute Medical Unit for further assessment. Lisa had been in her local supermarket with a friend when she suddenly felt light-headed and dizzy. Her symptoms were associated with a headache. She described the headache as a generalised pressure which was severe enough for her to sit down, as at one point she felt she was going to faint. Her vision had become blurred and her friend reported that her speech had been slurred. Differential Diagnosis Of Acute New Headache
 
She felt much better since arriving at hospital and apart from a persistent mild headache and some tingling in her hands (paraesthesia ) she felt fine. “I feel like I’m wasting your time”, she laughed nervously. Systemic and neurological examination was normal. Routine bloods had already been sent including a renal profile which came back showing a low serum bicarbonate level of 18. This got the alarm bells ringing. Arterial Blood Gas Basics


Something just didn’t add up and despite the pulse oximeter showing normal haemoglobin saturations of 99% on room air I proceeded to do an arterial blood gas from the radial artery.Taking An Arterial Blood Sample

 Lisa_ABG.png


She had a primary respiratory alkalosis with mild metabolic compensation. I went back to take a more complete history from Lisa with the causes of respiratory alkalosis in mind.Causes Of Respiratory Alkalosis

She was not taking any medications and her caffeine intake was low. Systemically she was well with no evidence of lung disease, fever, or meningitis.Hyperventilation And Hypoventilation

She then divulged that she had experienced a similar milder episode afew days ago when on a train. She was concerned that there was something seriously wrong. She wasn’t sleeping or eating well and felt exhausted all the time. She had recently broken up with herboyfriend and was finding work very stressful and had taken a significant amount of sick leave as she often felt light-headed and faint. She had become increasingly isolated from her friends. Neural Control Of Breathing

I felt Lisa was exhibiting psychological and biological symptoms of depression and on direct questioning she admitted to feeling depressed. The headache, paraesthesia and respiratory alkalosis could be explained by hyperventilation caused by anxiety and stress. I explained this to Lisa and she was relieved by the diagnosis. Symptoms Of Hyperventilation

I carefully outlined the case to the medical registrar on call, who agreed with my assessment. She still felt that a CT head and lumbar puncture were warranted in view of the persistent headache, but I worried about the risks of both procedures. We discussed the risk of missing a SAH diagnosis.

Several hours later, we were reassured that the CT head and LP were normal.

We had Lisa discharged and advised to see her GP for further management of her depression and anxiety.

It had been a typically busy Monday on acute medical take and the referrals just kept coming. “I’ve got another one for you”, the A&E F2 said, “a 26-year-old woman presenting with headache and neurological symptoms. I’ve discussed the case with my registrar and we feel she needs admitting to exclude a subarachnoid haemorrhage”.

Due to the 4-hour target she was whisked straight out of A&E and up to the Acute Medical Unit for further assessment. Lisa had been in her local supermarket with a friend when she suddenly felt light-headed and dizzy. Her symptoms were associated with a headache. She described the headache as a generalised pressure which was severe enough for her to sit down, as at one point she felt she was going to faint. Her vision had become blurred and her friend reported that her speech had been slurred. Differential Diagnosis Of Acute New Headache
 
She felt much better since arriving at hospital and apart from a persistent mild headache and some tingling in her hands (paraesthesia ) she felt fine. “I feel like I’m wasting your time”, she laughed nervously. Systemic and neurological examination was normal. Routine bloods had already been sent including a renal profile which came back showing a low serum bicarbonate level of 18. This got the alarm bells ringing. Arterial Blood Gas Basics


Something just didn’t add up and despite the pulse oximeter showing normal haemoglobin saturations of 99% on room air I proceeded to do an arterial blood gas from the radial artery.Taking An Arterial Blood Sample

 Lisa_ABG.png


She had a primary respiratory alkalosis with mild metabolic compensation. I went back to take a more complete history from Lisa with the causes of respiratory alkalosis in mind.Causes Of Respiratory Alkalosis

She was not taking any medications and her caffeine intake was low. Systemically she was well with no evidence of lung disease, fever, or meningitis.Hyperventilation And Hypoventilation

She then divulged that she had experienced a similar milder episode afew days ago when on a train. She was concerned that there was something seriously wrong. She wasn’t sleeping or eating well and felt exhausted all the time. She had recently broken up with herboyfriend and was finding work very stressful and had taken a significant amount of sick leave as she often felt light-headed and faint. She had become increasingly isolated from her friends. Neural Control Of Breathing

I felt Lisa was exhibiting psychological and biological symptoms of depression and on direct questioning she admitted to feeling depressed. The headache, paraesthesia and respiratory alkalosis could be explained by hyperventilation caused by anxiety and stress. I explained this to Lisa and she was relieved by the diagnosis. Symptoms Of Hyperventilation

I carefully outlined the case to the medical registrar on call, who agreed with my assessment. She still felt that a CT head and lumbar puncture were warranted in view of the persistent headache, but I worried about the risks of both procedures. We discussed the risk of missing a SAH diagnosis.

Several hours later, we were reassured that the CT head and LP were normal.

We had Lisa discharged and advised to see her GP for further management of her depression and anxiety.