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.
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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.
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