Moderator EMEDPA Posted September 17, 2013 Moderator Share Posted September 17, 2013 45 yr old AA female with h/a, vomiting, and blurry vision gradually worsening x months, now worse x 2 days. no prior hx of h/as. (hint, not your typical h/a). go! Link to comment Share on other sites More sharing options...
GreatChecko Posted September 17, 2013 Share Posted September 17, 2013 Whats the physical exam look like. HEENT especially. Any pain on palpation? Neuro s/s? Visual acuity, IOP? I'm thinking temporal arteritis or some sort of infarct/infection. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 17, 2013 Author Moderator Share Posted September 17, 2013 all good questions. let's start with vs. abnl are p= 125 and bp 160/92 good asking for VA: 20/50 r, 20/25 L + pain on palp of r globe IOP r=32, L =13 Link to comment Share on other sites More sharing options...
GreatChecko Posted September 17, 2013 Share Posted September 17, 2013 IOP on the right side, no bueno. I don't want to dilate due to the increased IOP (IIRC it's a contraindication) but what does the fundus look like (if you can see it)? Lack of a sudden onset tends to rule out closed angle glaucoma. I'm leaning towards an open angle glaucoma of some sort. Need to give her something to lower the IOP, what, I cannot remember at this time. Otherwise, the high IOP makes me want to consult ophtho, because I'm running into the limits of my current knowledge. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 17, 2013 Author Moderator Share Posted September 17, 2013 no papiledema, no obvious glaucomatous cupping but tough exam as pt light sensitive and intolerant of more than a few seconds eval. nice job. ophtho consult done. Timolol 0.5% 1 drop bid. next day ophtho f/u (12 hrs away as this is night shift) for presumptive new onset glaucoma. Link to comment Share on other sites More sharing options...
GreatChecko Posted September 17, 2013 Share Posted September 17, 2013 That's it?! Did I miss anything you did? Not surprised, but still surprised that I'm actually learning something in this marathon we call the first year of PA school. Crazy how it actually works.... Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 17, 2013 Author Moderator Share Posted September 17, 2013 That's it?! Did I miss anything you did? Not surprised, but still surprised that I'm actually learning something in this marathon we call the first year of PA school. Crazy how it actually works.... she actually had been previously seen a few weeks earlier and had a workup for "worst h/a of life" with ct, lp, sed rate, etc which was all neg so I knew what it wasn't from the start. Link to comment Share on other sites More sharing options...
GreatChecko Posted September 17, 2013 Share Posted September 17, 2013 Without the previous visit and in light of the increased IOP, would you still have elected for a CT and some labs to rule out the nastier intracranial differentials or would you be satisfied with the glaucoma dx? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 18, 2013 Author Moderator Share Posted September 18, 2013 probably still would have done the big workup if I was the first to see her. Link to comment Share on other sites More sharing options...
whoRyou Posted September 19, 2013 Share Posted September 19, 2013 Any blood work done? What meds? Does she take any, and if so what are they? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 19, 2013 Author Moderator Share Posted September 19, 2013 HX OF HTN ON LISINOPRIL. I DIDN'T DO ANY LAB WORK AS IT HAD ALL BEEN DONE ALONG WITH CT/LP AT PRIOR VISIT. BY THE TIME I SAW HER THE DX WAS MORE OBVIOUS. Link to comment Share on other sites More sharing options...
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