Kamsi
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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
A 45-year-old man presents to the emergency department with the chief complaint of upper abdominal pain, vomiting, and blurred vision, which started two hours ago after ingesting an unknown liquid. He has a history of alcoholism. The patient appears lethargic. His blood pressure is 100/60 mm Hg, with respirations of 24/min, and a temperature of 98.8 F. His pupils are 3 mm and reactive to light. Funduscopic examination reveals hyperemia of the optic disk bilaterally. There is no unusual odor of the patient's breath. Abdominal examination showed diffuse tenderness without guarding. The vomitus and stool are negative for occult blood. Neurological evaluation revealed no focal deficits. Laboratory studies reveal: sodium 136 mEq/L, potassium 4.1 mEq/L, chloride 97 mEq/L, bicarbonate 14 mEq/L, BUN 18 mg/dL, creatinine 1.0 mg/dL, and calcium 9.4 mg/dL. An arterial blood gas shows: pH 7.33, pCO2 33 mm Hg, pO2 93 mm Hg, and a bicarbonate of 15
mEq/L. The urinalysis is negative for glucose and protein, with no ketones or crystals. His osmolar gap is 12 mOsm/kg. Which of the following diagnosis is the most likely?
(A) Ethylene glycol intoxication
(B) Methanol intoxication
(C) Ethanol intoxication
(D) Isopropyl alcohol intoxication
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| Justice
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1. Bet on cluster HA - (A) Oxygen inhalation therapy... Initially thought about closed angle glaucoma
2. (B) Methanol intoxication… But wonder how one could ingest an unknown fluid
Edited by Justice on 09/13/07 - 02:32 PM
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| dermatology
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2. B methanol poisoining ...( eye changes)
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| sukhs
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1 is i think open angle glaucoma(i dont think there will b a refractive error and non reacting pupil in cluster headache).......so i will go with Acetazolamide
2 is methanol poisoning....
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| Justice
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sukhs wrote:
1 is i think open angle glaucoma(i dont think there will b a refractive error and non reacting pupil in cluster headache).......so i will go with Acetazolamide
2 is methanol poisoning....
In some patients with CH one can see ccular sympathetics paralysis - with mild ptosis, miosis, anhidrosis, but in this case it is not clear... I think in onen angle glaukoma one would see disk cupping on fundoscopy, but here the fundus is intact
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| usmle-china
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1. E. Pilocarpine
The patient has severe unilateral periorbital headache, red right eye, blurred vision, decreased vision, all these symptom suggest Acute Close-angle glaucoma, treatment is pilocarpine.
Open-angle glaucoma shoud have a gradually progressive visual field loss and optic nerve changes.
Closter headache can accompany with ipsilateral tearing, Horner's syndrome and nasal stuffiness.
2. B. Methanol intoxication
Hyperemia of the optic disk bilaterally is specific for Methanol intoxication.
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| njcjzy
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Both should be B.
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| sukhs
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kamsi..please give us the answer.Thanks
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| Kamsi
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1 B angle closure glaucoma b/c of the with eyes signs if not there would have been cluster headache
2 B Methanol intoxication Bilateral optic disc hyperemia is specific for it,CNS depression, acidosis,absence of ketosis or abnormal breath,severe anion gap,tachypnea
Ethylene glycol intoxication; CNS depression,acidosis,nephrotoxicity,calcium oxalate crystals in urine
Ethanol intoxication: CNS depression,abnormal breath odour,ketosis
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| usmle-china
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1. The treatment of acute closure glaucoma is pilocarpine or Acetazolamide ?
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| sunny2
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Treatment of acute closure glaucoma is - Acetazolamide, a topical beta-blocker, and a topical steroid.
Aceta + Beta : lowers IOP and decrease aqueous humor production and enhance opening of the angle.
Why not Pilocarpine - because it constricts the ciliary muscle and increases the axial thickness of the lens and also induce anterior lens movement, this could result in reducing the depth of the anterior chamber and worsening the clinical situation in a paradoxical reaction.
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| dr in trouble
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Good Qs
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