Case Study: Worsening Headache After Giving Birth

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History of Present Illness and Physical Examination

A 32-year-old woman presents to the emergency department 8 days after vaginally delivering her second child complaining of gradually worsening generalized headache that started the night before her visit.  She denies fever, vomiting or stroke-like symptoms. She also describes pleuritic bilateral rib pain that is worse on the right and is associated with shortness of breath and leg edema. She denies other complaints.

The patient's vital signs include the following: pulse 58 bpm, blood pressure 177/95 mm Hg, respiratory rate 22, and temperature 97.8◦F.  Physical examination is normal except for diminished breath sounds on the right and 1+ bilateral pitting leg edema without redness.  Neurologic exam is normal.

Differential diagnoses include post-lumbar puncture headache following epidural, cerebral venous sinus thrombosis, pre-eclampsia, pulmonary embolism, and postpartum cardiomyopathy.

Laboratory workup was normal except for D-dimer >20, aspartate aminotransferase (AST) 100 U/L, and alanine aminotransferase (ALT) 150 U/L. Electrocardiography shows sinus bradycardia. Chest radiograph is shown below.

What does the image show? What should you do next? 

Click to the next page for answers.

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