Severe Headache in a Patient After Lumbar Puncture

Vital Signs

• Temperature: 101.6 °F, axillary

• Blood Pressure: 142/70 mmHg

• Heart Rate: 92 beats per min (bpm) - normal sinus rhythm on telemetry

• Respiratory Rate: 16 breaths per min

• Pulse Oximetry: 98% saturation on room air

Focused Physical Examination

A focused exam revealed a young female lying completely flat and still in her bed. She was awake, alert, and appropriately oriented. Her cranial nerve testing was unremarkable. Finger-nose-finger testing did not demonstrate any dysmetria. Sensations were equal and intact to all of her extremities. There was no gross motor weakness noted. The patient was cooperative with the physical exam, but she was confused regarding recent events. She was warm to the touch. There was positive nuchal rigidity and Brudzinski’s sign. Her cardiac exam demonstrated regular rhythm and rate. Her lungs were clear. She did not have any abdominal tenderness. She stated that any movement whatsoever makes her headache worse, but her pain does not seem as bad if she lays still. She reported that she did not have any vision problems but would like the rapid response team to shut off the lights if possible.

Interventions

The rapid response team reviewed the ER notes, laboratory test reports, and imaging studies. The patient had an elevated white blood cell count of 14.2 K/uL with the rest of the complete blood count without any significant abnormalities. Her basal metabolic panel was normal. She had a computed tomography (CT) scan of her head, which was also normal. She had a lumbar puncture in the ER, and her cerebr ospinal fluid (CSF) studies were consistent with bacterial meningitis. There was a large number of red blood cells in the first CSF tube but an almost negligible number in the last CSF tube. The CSF gram stain and culture were still pending at the time of the rapid response. The rapid response team did not order any additional labs or imaging, but interventional radiology was contacted to perform an epidural blood patch urgently. After returning from the radiology department, the patient reported that her headache was gone, and she could move around in bed without having any distress.