Author: Hind Goriel / Editor: Sarah Edwards / Codes: ACCS LO 2, NeuC12, NeuP1, NeuP2, NeuP8, SLO1 / Published: 12/08/2022

A 21-year-old female patient presents to the Emergency Department (ED) in the morning. She was brought in by her family after they were unable to wake her up. The family stated that their daughter was unwell for the last 3-days complaining mainly of headache, neck pain and dizziness. She has been to the local outpatient clinic and was diagnosed with tension headache for which she was given paracetamol but not much response noticed. There was no history of trauma or fall.

She has no past medical history. She is a non-smoker and does not drink any alcohol.

Upon arrival to the ED, the patient was unresponsive. Her blood pressure was 110/68 mmHg, heart rate 93 beats per minute, temperature 36.7°C and oxygen saturation 100% in air. The pupils were equal and are 4 mm size, round and reactive to light; the oropharynx was clear; and the neck was flexible. Precordial examination showed audible regular heart sounds with no murmur, the lungs were clear bilaterally with good air-entry, and the abdomen was not distended, soft and not tender to palpation. No lesions noted on exposure and peripheral pulses were positive. The Glasgow Coma Scale (GCS) score was 7 with eyes closed, nonverbal with withdrawal from pain.

The gag and corneal reflexes were normal. Hyper-reflexion noted in all body tendons. A CT-head without contrast was negative for bleeding or ischemia. Her full set of blood tests showed no abnormality.

Venous blood gas showed pH 7.41, pCO2 5.1, pO2 9.2 and bicarbonate 20.1 mEq/L. Glucose was 6.5 mmol/L.

ECG showed normal sinus rhythm with no evidence of ischemic changes or conduction abnormality.

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