Can you please answer as soon as possible.
A 34-year-old attorney wins a two-million-dollar judgment against an HMO on Friday afternoon. After celebrating with champagne that evening, he experiences an episode of flashing lights beginning in his right visual field and moving slowly. Twenty minutes later this visual disturbance resolves but he develops left-sided throbbing headache which builds to maximal intensity over 3 hours. Activity makes the headache worse. He feels better lying down in a dark room. Medical history is significant only for motion sickness as a child. His mother has hypertension and migraine headache.
Physical:
BP 122/64 HR
78 T 37.8°C Pulse
Ox 98%
General: Thin. Appears ill, asking for the lights
to be turned off.
Mental Status: Oriented. MMSE not done.
HEENT: The head was normocephalic and without
bruising. Neck was supple, with full range of motion. The pupils
were equal, round and reactive to light and there was no relative
afferent pupillary defect. Extraocular movements were intact
without nystagmus. Visual field testing was full to confrontation.
Optic discs were sharp bilaterally with venous pulsations present.
There was no facial weakness. Facial sensation was intact
bilaterally. The palate elevated symmetrically. The tongue was
midline and strong.
Motor (Power/Tone/Bulk): 5/5 bilaterally in the
upper and lower extremities. No pronator drift. Tone was normal. No
atrophy.
Sensory: Sensation was intact to light touch, pin
prick and proprioception bilaterally in the upper and lower
extremities. Romberg sign was absent (a normal finding).
Reflexes: 2/4 at the left biceps, triceps,
brachioradialis, patella and Achilles, and 2/4 on the right. Both
toes downgoing to plantar stimulation.
Coordination: Finger-to-nose and rapid alternating
movements were intact bilaterally.
Gait: Steady but slow, without ataxia. Tandem
walking not done.
Abnormal Movements: None
Other Organs: Noncontributory.
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