doc_clotaire
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A 38-year-old nurse comes to the emergency department after leaving work early because of a "horrible headache." She has had a "cold" with sinus congestion for the past week, and yesterday she began taking an over-the-counter combination of diphenhydramine and pseudoephedrine. She tells you she has a history of "migraines," multiple allergies, premenstrual syndrome and depression, for which she takes phenelzine (a monoamine oxidase inhibitor). Vital signs are: temperature 37.2°C (99.0°F), pulse 90/min, respirations 16/min and blood pressure 210/118 mm Hg.
Which of the following is the most appropriate action?
(A) Administer meperidine, intramuscularly
(B) Administer phentolamine, intravenously
(C) Order CT scan of the head
(D) Order transillumination of the sinuses
(E) Prescribe oral oxycodone and nasal corticosteroids
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| new_n_lost
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(B) Administer phentolamine, intravenously ??
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| Justice
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It sounds to me that all the drugs the Pt is taking could cause vasoconstriction, alone or in combination... It could be that the Pt now has subarachnoid hemorrhage...
I go with (C) CT scan...
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| Justice
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And just noted: PB 210/118 mm Hg... Yea, I offer (C)
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| Justice
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new_n_lost wrote:
(B) Administer phentolamine, intravenously ??
Although this would help to lower the PB down... Is it safe in Pt with subarachoind hemorrhages?
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| new_n_lost
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yup U r Right Abt that Point cos if its a SubArachnoid Hemorrhage then C wud be the Next Step but She is a Migraine Pt her Classification of a horrible headache seems that it isnt the worst headache ever of her life ( which in Subarchnoid Hemorrhage is a cardinal indication) so thats y i choose B lets wht answer is . Secondly she is on MAOI which have SE of Hypertensive Crisis. Alongwith 2 Antihistamines so it can lead to a HTN crisis.
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| vradojc1
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FYI, not every patient with SAH (in real life or test) will state "the worst headache" of its life.
This is (from findings and history) MAOI induced hypertensive crisis. What should point you to that is the Phenelzine (MAOI) + antihistamine + sympathomimetic. I would go with phentolamine since it is preferred treatment for the condition (or labetalol/hydralazine).
If she would have meningeal signs (which are quite common in SAH/+fever as well) I would opt for CT.
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| new_n_lost
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FYI Signs of Meningeal Irritation do occur in SAH but take Several Hrs to develope n till then if its the Ruptured Aneurym then she will have a possible cranial nerve palsy or depending upon the location of the Aneurysm.
Sentinel Headaches alongwith Nuchial Rigidity or a Sudden Onset Very Severe Headache ( Worst One Ever ) is described Example Sharon Stone When She had a SAH for references Plz see Harrison and Washington Manual and the following link.
http://content.nejm.org/cgi/content/full/342/1/29
The typical patient with subarachnoid hemorrhage has a sudden onset of severe headache (frequently described as being the worst headache of his or her life) that develops during exertion. Transient loss of consciousness or buckling of the legs often accompanies the headache. Vomiting soon follows
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| doc_clotaire
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The correct answer is B.
This patient has hypertension secondary to the effects of
the pseudoephedrine and her monoamine oxidase inhibitor. The inhibition of MAO-A
causes the rise of norepinephrine, dopamine and serotonin in the synaptic cleft, of MAOB
only of dopamine. Pseudoephedrine displaces norepinephrine from synaptic terminals.
For this reasons, nasal sprays such as the one this patient is taking are to be avoided when
MAOIs are used. Phentolamine is a reversible alpha-adrenergic receptor blocker that will
blunt the effects of the excess catecholamines on arteriolar vasoconstriction.
Meperidine (choice A) is a narcotic and is used for pain control. Managing this patient’s
headache is reasonable once it is certain that her hypertension is not the cause. By
masking the pain and not managing the blood pressure, there remains a serious risk of
hemorrhage or stroke with this patient.
A CT scan of the head (choice C) is not indicated as a source for this patient’s headaches
is evident from the history. A CT is useful when no such hints exist and there is a concern
for intracranial pathology based upon the presenting signs and symptoms.
Transillumination of the sinuses (choice D) is a tool to aid in the diagnosis of sinusitis.
This patient is known to have sinusitis by her history and therefore, re-conforming the
presence of active infection will do nothing to help address her current active issue of
hypertensive crisis, bordering on emergency (symptomatic).
Once it is certain that the cause of this patient’s headache is not the blood pressure, it is
completely reasonable to manage her solely as a sinusitis patient and prescribe oral pain
medications and intra-nasal steroids (choice E). However, it is critical that the blood
pressure first be lowered and then it can be excluded as a cause for her current symptoms.
Good Call NnL 
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