History of Present Illness (HPI)

A 22-year-old female, who is 37 weeks pregnant (G2P1001), presents with a one-month history of chronic headaches. The headaches are described as throbbing, primarily located on the left side of her head, and are associated with photophobia, which is worse in her left eye. Additionally, she has experienced numbness on the left side of her face for the past 5 days without any motor involvement. Recent episodes have also included symptoms of dizziness and seeing floaters. Despite multiple visits to the emergency department and being prescribed Stadol, she has seen minimal relief from her symptoms.

Differential Diagnosis

• Single Most Likely Diagnosis
  • Migraine with Aura: This diagnosis is likely due to the patient's symptoms of throbbing headache, photophobia (worse on one eye), and transient neurological symptoms such as numbness and visual disturbances (seeing floaters). The pregnancy state can sometimes exacerbate migraine symptoms.
• Other Likely Diagnoses
  • Pregnancy-Induced Hypertension (PIH) with Headache: Although the patient's labs (e.g., UPC, Scr, AST, ALT, platelets) are currently normal, PIH can sometimes present with headaches and visual disturbances. The absence of elevated blood pressure readings in the provided information does not rule out this condition entirely, as it can fluctuate.
  • Posterior Reversible Encephalopathy Syndrome (PRES): This condition, associated with hypertension and preeclampsia, can cause headaches, visual disturbances, and sometimes seizures. The patient's symptoms of headache, dizziness, and seeing floaters could align with PRES, although typically, it is associated with more severe hypertension and seizures.
• Do Not Miss Diagnoses
  • Preeclampsia with Severe Features: Despite normal labs, preeclampsia can rapidly evolve, and severe features include severe headache, visual disturbances, and sometimes numbness or tingling. It is crucial to monitor blood pressure closely and consider the possibility of preeclampsia, even with currently normal lab values.
  • Cerebral Venous Thrombosis (CVT): This condition can present with headache, visual disturbances, and sometimes focal neurological deficits like numbness. Pregnancy is a hypercoagulable state, increasing the risk of CVT. It is a critical diagnosis not to miss due to its potential for severe outcomes if not treated promptly.
• Rare Diagnoses
  • Reversible Cerebral Vasoconstriction Syndrome (RCVS): This condition can cause severe headaches (often described as "thunderclap") and sometimes visual disturbances. It is more rare but should be considered, especially if other diagnoses are ruled out and the patient's condition worsens or does not improve with standard treatments.
  • Arteriovenous Malformation (AVM) or Aneurysm: Although rare, these vascular abnormalities can cause headaches, visual disturbances, and sometimes focal neurological symptoms. Pregnancy can increase the risk of rupture, making these diagnoses critical to consider and rule out, especially with imaging studies.