Aashi
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A 32-year-old woman with no significant past medical history comes to your office complaining of a severe headache. She describes a severe unilateral, nonpulsating, periorbital pain for about two hours. The patient has noticed that her right eye is red. She does not associate the headaches with any specific activity, food, or stressors. She denies fever or chills and has used ibuprofen and acetaminophen without relief. She is afebrile and has a blood pressure of 144/76 mm Hg. Physical examination reveals a morbidly obese female with a nontender face, temporal arteries, and sinuses. There is no neck stiffness. Her right eye is injected. The pupils are equal and round, but the right eye is nonreactive. The patient complains of blurred vision. Visual acuity testing shows 20/40 on the right and 20/20 on the left. Funduscopic and neurological examinations are normal. What would be the next step in the management of this patient?
(A) Oxygen inhalation therapy
(B) Acetazolamide
(C) Head CT scan
(D) Prednisone for 10 days, followed by rapid taper
(E) Pilocarpine
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| doc_clotaire
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a ) Oxygen inhalation therapy ( This is CLUSTER HEADACHE )
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| CocaCola
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sounds like cluster headache to me also...
a- O2 therapy is the best initial therapy
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| mjl1717
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yes, episodic conjuctivitis with maybe lacrimation and rhinnorhea.
prophylactic Rx might be ergots, CCB, or valproic acid, or topiramate
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| fox
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I beg to differ...I think this could well be a case of angle closure glauc.......maybe rx is acetazolamide methinks.
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| chemamr
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yeah, I'm confused between closed angle glaucoma or cluster headaches. How can you distinguish them at this clinical case??.
Edited by chemamr on 02/12/07 - 04:50 PM
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| vrach
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B) Acetazolamide; This can not be a cluster headache because they usually don't last more than 2 hours, and although they may have horners syndorme their pupils are reactive to light and they do not have blurring of vision. This is probably acut angle closure glaucoma because pupils are not reactive to light, and vision is decreased.
Edited by vrach on 02/13/07 - 06:57 AM
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| Aashi
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Answer:
(B) Acetazolamide
Explanation:
Because of this patient's history of headache, blurry vision, and a nonreactive pupil, this patient has acute-angle closure glaucoma. When the pupil becomes mid-dilated, the peripheral iris blocks aqueous outflow via the anterior chamber angle, and the intra-ocular pressure rises abruptly, producing pain, injection, corneal edema, and blurred vision. It is best treated acutely with acetazolamide to lower intraocular pressure. Topical beta-blockers can be used on a long-term basis to prevent an increase in intraocular pressure. Pilocarpine can be used to induce miosis and lower intraocular pressure as well, but it should be started after the acetazolamide. The symptoms of acute-angle closure glaucoma are similar to cluster headaches. These include a unilateral, nonthrobbing headache and the association with parasympathetic over activity, such as lacrimation, rhinorrhea, and injected conjunctiva. Cluster headaches last 30 minutes to two hours, are seen more often in men than woman, and often occur at the onset of sleep. Patients are usually hyperactive during the headache. Given the history of sudden headaches with no prior episodes and the nonreactive pupil, this patient is not likely to have cluster-type headaches. Oxygen inhalation and prednisone can be used to acutely treat cluster headaches.
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| chemamr
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good question.
Edited by chemamr on 02/13/07 - 04:17 AM
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| webjeee
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why not Pilocarpine?
please explain.
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| neuroblastoma
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Pilocarpine can be used to induce miosis and lower intraocular pressure as well, but it should be started after the acetazolamide.
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| Justice
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(B) Acetazolamide
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