# Very Odd



## Voodoo1 (Dec 13, 2011)

39 Y/o male, history of schizophrenia, bi polar disorder, psychosis, and edema
Pt's c/c is of constant throbbing pain in the cervical spine that radiates to the back of his head. He says that it feels like somebody is punching him in the skull all day long. Pt also complains of numbness, pins and needles and loss of strength in all four limbs. His wife says that he gets hot and cold very quickly and has noticed a change in his body odor. She said it's almost a sweet smell. Cold compresses on forehead help with pain, laying down in any position makes it worse. Unknown family history of any major illnesses. Wife states that there has never been any changes in behaviour or in consciousness. 
The initial incident that brought about his symptoms happened while he and his wife were having sex. His wife said that he got very red in the face and and his head started to pound and throb, he was complaining of being very lightheaded and 10 minutes afterwards thought he had a migraine. The symptoms have lasted for two weeks with no reprieve. 
He has been tested for diabetes, thyroid imbalance, infectious causes and all have come back negative. Pt has not been running a fever, any difficulty of breathing or has had any signs of TIA or CVA. 
He has been refered to neuro, had a CAT done, nothing abnormal. 
Any ideas???


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## JPINFV (Dec 13, 2011)

Do you know what medications he was on, as well as if there had been any changes recently?


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## systemet (Dec 13, 2011)

Voodoo1 said:


> His wife says that he gets hot and cold very quickly and has noticed a change in his body odor. She said it's almost a sweet smell.



Blood sugar?


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## Anjel (Dec 13, 2011)

systemet said:


> Blood sugar?



It said he was tested for diabetes. But that was my first thought as well.


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## FlamingFirefox (Dec 14, 2011)

change in body odor could sometimes be related to digestive issues,there could be issues with his liver,the liver stores glucose,maybe he's releasing stored glucose,thats what might cause the sweet body odor,just my 2 cents.


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## mycrofft (Dec 14, 2011)

*Headaches post a sexual congress and recurring thereafter.*

Many people have a tremendous urge to Valsalva during sex, some so much that they (arrange to ) strangle themselves. Increase in ICP could conceivably develop a nascent aneurysm? Or even a small ("small" meaning "it wasn't me") intracranial bleed. Also, other maneuvers could have resulted in a cervical strain or other damage.

Quick, Watson, the long spine board!

As for smells and feeling, these are subjective, give me thermometer readings, gooseflesh, fingerstick glucometry and urine dipsticks anyway.
Basic VS and Hx, including meds, no obvious screaming emergency.


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## usafmedic45 (Dec 14, 2011)

> Or even a small ("small" meaning "it wasn't me") intracranial bleed.



You know you can also get EDHs in your spinal canal right?


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## mycrofft (Dec 14, 2011)

*Extra-dural hemorrhage?*

No thanks one is fine.

Never thought about it.How common? At the risk of triggering a juvenile avalanche of BS, it would be interesting to see what experiences we have had revolving around illnesses relating to "sexual congress".
Or as Sheldon likes to call it, "coitus".


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## usafmedic45 (Dec 14, 2011)

mycrofft said:


> No thanks one is fine.
> 
> Never thought about it.How common? At the risk of triggering a juvenile avalanche of BS, it would be interesting to see what experiences we have had revolving around illnesses relating to "sexual congress".
> Or as Sheldon likes to call it, "coitus".



The very first EDH I ever encountered clinically was a cervical spinal canal epidural hemorrhage and started while the patient was having sex with his wife (who happened to be one of our ED nurses).  I'm not sure how common it is for extracranial EDHs to present clinically.  I've seen three in live patients in fifteen years that I'm aware of and encountered two more at autopsy during my research into aircraft crash injury patterns.


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## mycrofft (Dec 14, 2011)

*Here's a seminal article from 1963. Pun unintended.*

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1922131/?page=2

These things can be just lying in wait.


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## Remeber343 (Dec 16, 2011)

You say they have lasted for two weeks...?  What makes this different from the last two weeks?  Why call 911 now?


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## Handsome Robb (Dec 16, 2011)

photosensitivity? How about ROM on the neck? Febrile? Been sick lately? Where exactly does it hurt in his head? (might have missed the answer to that one in the OP) Vitals? Any odd exposures? Changes in diet, activities? Illness in close friends/family?


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## mycrofft (Dec 16, 2011)

*Stick with the prurient NV!*

Sweet smell reported by wife=> other woman's perfume. Other c/o=> pt doesn't want sex with wife anymore.

Yeah, an infectious encephalopathy can't be ruled out, they can just really  linger.

 Longstanding headaches can radiate so it can be hard to ascertain any useful location. I've had pts indicate "headband", and "over the top" (nuccal to forehead, or vice versa, rarely transversely ear-ro-ear) when the originating pain site was, respectively, supraorbital (sinuses) and nuccal (poor ergonomics with mild cervical strain). And others.


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## Handsome Robb (Dec 16, 2011)

mycrofft said:


> Sweet smell reported by wife=> other woman's perfume. Other c/o=> pt doesn't want sex with wife anymore.
> 
> Yeah, an infectious encephalopathy can't be ruled out, they can just really  linger.
> 
> Longstanding headaches can radiate so it can be hard to ascertain any useful location. I've had pts indicate "headband", and "over the top" (nuccal to forehead, or vice versa, rarely transversely ear-ro-ear) when the originating pain site was, respectively, supraorbital (sinuses) and nuccal (poor ergonomics with mild cervical strain). And others.



I agree haha. That is a very plausible option. With that said what about neurosyphilis, even though it doesn't fit all that well h34r:

But like you said encephalopathy can't be directly ruled out but I'd be more comfortable if I did what I could to rule it out for my own piece of mind. Otherwise homeboy might be wearing a HEPA mask in my unit


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## Veneficus (Dec 16, 2011)

was he on clozapine?


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## Voodoo1 (Dec 20, 2011)

I'll have to check back to see what kind of meds he's on. No recent illness, no fever, I can't remember vitals right now, full ROM and no complaints about photosensitivity. Last I heard pt was being seen by neuro December 27th (wife told me). I am very interested to see what's going to turn up.


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