Intern Report Case Presentation 2.7

intern-report

Presented by Daniel Seitz, MD

CC: “I’m coughing up blood”.

HPI: A 44-year-old man presents to the Emergency Department complaining of coughing up blood for two days.  The patient states that two months ago he began experiencing progressively worsening cough and fatigue.  The cough was initially non-productive, but for the past month he’s been coughing up thick yellow sputum.  One week ago he noticed that his sputum was intermittently blood streaked, and yesterday he coughed up gross blood.  Over the last 24hrs the patient reports coughing up a cup and a half of gross blood.  He describes the blood as bright red, frothy and devoid of food particles.  He also reports a history of weight loss, approximately 20lbs in the last 6 months. The patient occasionally has fevers in the afternoon, and reports night sweats over the past three weeks. The patient states that he experiences a diffuse achy pain on deep inhalation and with cough.  He denies any shortness of breath or difficulty breathing.

ROS: Negative except for as mentioned in the HPI.
PMH: Hypertension which he’s treating with diet and exercise.
PSH: Denies.
Medications: None.
Allergies: No known drug allergies.
FH: Hypertension, heart disease, and diabetes.
SH: The patient smokes 1 pack per day, has smoked for ten years, occasionally drinks alcohol, and denies any illicit drug use.  The patient lives alone and works as an actuary.  He was born in China and immigrated to the United States as a teenager.

PE:
VITAL SIGNS: BP 92/55, P 109, R 21, T 38.4, SpO2 95% on room air.
GENERAL: Patient is sitting comfortably in his stretcher and is in no apparent acute distress.
HEAD: Head is atraumatic, normocephalic, and no tenderness to palpation.
EYES:  Mild conjunctival pallor.  Pupils are 4 mm bilaterally, are equally round and reactive to light and accomodation.  No nystagmus.  No conjunctival injection, but mild conjuctival pallor.  No scleral icterus
EARS: Tympanic membranes are normal.
NOSE: No nasal drainage, no blood in nares, no swollen turbinates.
MOUTH:  Dried  blood around the patient’s mouth.  Moist mucous membranes, no tonsillar enlargment or exudates, no intraoral lesions.
NECK: Supple without lymphadenolpathy.  There is no nuchal rigidity, no tenderness to palpation, no carotid bruits, trachea is midline.
CARDIOVASCULAR: S1, S2, tachychardic rate with normal rhythm.  No murmurs, rubs or gallops.  Peripheral pulses are present , 2+, and symmetric in all four extremities.
RESPIRATORY: Good air entry bilateral.   Diffuse post-tussive rales, distant breath sounds heard over the lung apices .
GASTROINTESTINAL: Abdomen soft, non-tender, non-distended, no tenderness to palpation, no appreciable organomegaly.  Bowel sounds present in all quadrants.
MUSCULOSKELETAL: Patient is mildly cachexic.  Strength 5/5 proximally and distally in all extremities.
SKIN:  No rashes, lesions or ulcerations.  Increased pallor.
NEUROLOGIC: Patient is awake, alert and oriented to person, place and time.  Face is symmetrical.  Sensation is equal and intact throughout.  The patient walks with a normal gait and performs finger to nose examination without difficulty.

Course in the ED: While waiting to be seen in the module, the patient expectorates 700 mLs of gross blood.  The patient is rushed to resuscitation; where he’s placed on a monitor and two large bore peripheral IVs are placed.  A stat portable chest x-ray is obtained which shows a cavitary lesion at the apex of the patient’s left lung.  The patient’s vital signs in resuscitation are as follows:  T: 38.6 HR: 112 RR: 25 BP: 81/50 O2Sat: 87% on non-rebreather.

Questions

What is the patient’s most likely diagnosis?
a) Lung cancer
b) Tuberculosis
c) Aspergillosis
d) Pneumonia
e) Bronchitis

Which of the following characteristics indicates hematemesis over hemoptysis?
a) Alkaline pH
b) Dark color
c) Frothy appearance
d) Presence of macrophages

What is the best course of management in this patient?
a) Emergent angiography
b) Flexible Bronchoscopy
c) Intubation of the right main stem bronchus, and place patient in left lateral decubitus position
d) Rigid Bronchoscopy
e) Rush the patient to the operating room for emergent thoracotomy

What vessel is most likely responsible for this patient’s massive hemoptysis?
a) Aorta
b) Bronchial artery
c) Inominate artery
c) Pulmonary artery
d) Tracheobronchial capillaries

Please submit your answers to the questions in the “leave a reply” box or click on the “comments” link.  Your submission will not immediately post.  Answers with a case discussion will post on Friday.  If you have any difficulty, please contact the site administrator at arosh@med.wayne.edu. Thank you for participating in Receiving’s: Intern Report.

Intern Report Case Discussion 2.6

intern-report

Presented by Claire Jensen, MD

CC: “She passed out,” per EMS.

HPI: A 63 year-old African-American female presents to the emergency department by ambulance following a witnessed syncopal episode at a casino.  Upon her arrival in the ED, the majority of the history is obtained from EMS as the patient is actively vomiting.  She was seated at a slot machine with friends when she suddenly slumped to the floor unconscious.  She did not complain of feeling ill and was acting normally prior to the syncopal episode.  Within seconds of landing on the floor, she regained consciousness.  Initially she was somewhat slow to respond, but was alert and oriented, responding normally by the time the paramedics arrived.  She vomited once, and was transported to the ED.  A blood sugar was obtained in the field, 130 mg/dL.  Upon arrival, she complains of “just not feeling well” and continues to vomit.  She also complains of severe headache “all over” and some blurred vision. She denies vertigo, chest pain, shortness of breath or abdominal pain.

ROS: Negative except as mentioned in the HPI.

PMH: Denies.

PSH: Denies.

Medications: None.

Allergies: None known.

FH: Hypertension.

SH: Life-long non-smoker, non-drinker, and does not use illicit drugs.

PE:

VITAL SIGNS: BP 200/104, P 102, R 16, T 36.3, SpO2 99% on room air.

GENERAL: Alert and oriented x3, initially answers questions appropriately, diaphoretic, moderate distress from vomiting.

HEENT: Head is atraumatic, normocephalic.  Pupils are 2 mm bilaterally and minimally reactive to light.  Mild disconjugate gaze is noted, with slight temporal deviation of the left eye.  No nystagmus.  No conjunctival injection or pallor.  No scleral icterus.  Funduscopic exam attempted but unable to perform due to the patient’s continued vomiting.  Tympanic membranes are normal.  No nasal drainage.  Moist mucous membranes, no tonsillar enlargement.

NECK: Supple without lymphadenolpathy.  There is no nuchal rigidity, no carotid bruits.

CARDIOVASCULAR: Tachycardic, normal S1, S2, without murmurs, rubs or gallops.

RESPIRATORY: Lungs are clear to auscultation bilaterally.

GASTROINTESTINAL: Abdomen obese, soft, non-tender, non-distended, without masses or organomegaly.  Bowel sounds present.

MUSCULOSKELETAL: Normal muscle bulk and tone.  No deformities.  Unable to perform muscle strength testing due to patient’s decreasing ability to follow commands.  She moves all extremities spontaneously.  Peripheral pulses are 2+ and symmetric in all four extremities.

NEUROLOGIC: Unable to assess orientation due to patient’s continued vomiting, The patient is noted to have increasing difficulty following commands.  Disconjugate gaze as noted above.  The face is symmetric.  DTRs were not assessed.  Babinski is down-going bilaterally.

Near the completion of the physical exam, the patient suddenly became unresponsive with snoring respirations and minimal gag reflex.  IV access was obtained, and the decision was made to intubate the patient so that emergent CT scan of the head could be obtained.

Questions

1.  This is the patient’s CT (without contrast).  What is the diagnosis?

________

A.  Brain tumom

B.  Epidural hematoma

C.  Interparenchymal hemorrhage

D.  Subarachnoid hemorrhage

E.  Subdural hemorrhage

__________

2.  Which medication should be considered for use as an adjunct to rapid sequence induction in this patient?

A.  Atropine

B.  Defasciculating dose of vecurionium

C.  Fentanyl

D.  Ketamine

E.  Morphine

__________

3.  A 49 year-old man presents after he fainted while running on his treadmill at home.  He has been having exertional dyspnea and angina for the past several months.  Which of the following cardiac diseases is most likely to cause these symptoms.

A.  Aortic stenosis

B.  Atrial septal defect

C.  Mitral incompetence

D.  Pulmonary stenosis

E.  Tricuspid incompetence

______________

Answers

1. D     Subarachnoid hemorrhage

2. C     Fentanyl

3. A     Aortic stenosis

Discussion

Syncope is defined as transient loss of postural tone followed by rapid and full recovery, typically upon assuming a supine position.  True syncope is an uncommon, yet recognized, presenting symptom of subarachnoid hemorrhage.  The differential diagnosis of syncope is incredibly broad, and potential etiologies range from the benign to the catastrophic.  The symptom of syncope itself can also be dangerous in that it predisposes the patient to traumatic injury.  As with any chief complaint, narrowing the differential begins with a thorough history and physical exam, and it is incumbent upon the emergency physician to rapidly integrate the information gleaned in order to be selective about which diagnostic modalities (and in what order) will best elucidate the root cause of the event.  A “shotgun” approach to the evaluation of syncope is low-yield and can actually slow the identification of the cause.

In this case, the patient presented with true syncope and was found to have subarachnoid hemorrhage secondary to aneurysm rupture.  Her complaints of severe headache and nausea and the physical findings of hypertension, disconjugate gaze and rapidly declining level of consciousness all support the diagnosis.  After management of airway, breathing and circulation, she was taken for CT of the head, which immediately revealed her diagnosis and allowed rapid mobilization of consulting services and definitive therapy.

Syncope is a common chief complaint in the ED, accounting for 1-3% of visits annually.  “Pre-syncope” or “near-syncope” accounts for yet more visits and should be considered on the same spectrum and approached similarly. Frequently, despite thorough evaluation by the emergency physician, a cause is not identified.  Therefore, risk stratification of the patient with syncope, taking into consideration co-morbid conditions and access to rapid follow-up, should occur simultaneously with diagnostic evaluation, as it ultimately impacts disposition.  The San Francisco Syncope Rule provides a simple mnemonic (CHESS) to assist the clinician in risk-stratification of patients presenting with syncope:

C – History of congestive heart failure

H – Hematocrit <30%

E – Abnormal EKG

S – Shortness of breath

S – Triage systolic blood pressure <90 mgHg

A patient with any one of these criteria is considered to be high risk for a serious outcome (death, myocardial infarction, pulmonary embolism, stroke, subarachnoid hemorrhage, significant hemorrhage, return to the ED or hospitalization for a related event.)  Various studies to validate the SFSR have reported sensitivities of 74-98%.

Clinical Pearls

  • The differential diagnosis of syncope is exceedingly broad.  A thorough history is the first step in narrowing the differential, with particular attention to other associated symptoms, and will guide the selection of diagnostic tests.
  • Pre-syncope is another common ED chief complaint, and often presents as “weak and dizzy.”  It is important to distinguish between pre-syncope and vertigo.  Both may be accompanied by headache, nausea, tinnitus, and other symptoms.  A useful tactic is asking the patient about a sense of the room spinning about them, which is indicative of vertigo.
  • Subarachnoid hemorrhage is one of the key “don’t miss” diagnoses in emergency medicine.  When reasonable clinical suspicion exists, a negative CT scan should be followed by lumbar puncture to satisfactorily exclude SAH.
  • Patients with subarachnoid hemorrhage can deteriorate rapidly and may require emergent airway management.  Lidocaine has traditionally been used as an adjunctive medication during intubation of patients with known or suspected elevated intracranial pressure to blunt further rise in ICP, although the studies to support this are few, limited, and sometimes equivocal.  Ultra-short acting opioids such as fentanyl are well-documented to blunt the sympathetic response  (and thus rise in ICP) to airway instrumentation and should be considered as well

Special thanks to Marjan Siadat, M.D. for her assistance with this case.

References

1. Bederson JB, Connolly ES Jr, Batjer HH, Dacey RG, Dion JE, Diringer MN, Duldner JE Jr, Harbaugh RE, Patel AB, Rosenwasser RH; American Heart Association. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 2009 Mar;40(3):994-1025. Epub 2009 Jan 22. Review. No abstract available. Erratum in: Stroke. 2009 Jul;40(7):e518.

2.  de Rooij, NK, Linn, FH, van der, Plas JA, et al. Incidence of subarachnoid haemorrhage: a systematic review with emphasis on region, age, gender and time trends. J Neurol Neurosurg Psychiatry 2007; 78:1365.

3.  Molyneux AJ, Kerr RS, Birks J, Ramzi N, Yarnold J, Sneade M, Rischmiller J; ISAT Collaborators. Risk of recurrent subarachnoid haemorrhage, death, or dependence and standardised mortality ratios after clipping or coiling of an intracranial aneurysm in the International Subarachnoid Aneurysm Trial (ISAT): long-term follow-up. Lancet Neurol. 2009 May; 8(5):427-33.

4.  Quinn J, McDermott D Stiell I, Kohn M, Wells G.  Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes.  Ann Emerg Med. 2006 May; 47(5); 448-454.

5.  Birnbaum A, Esses D, Bijur P, Wollowitz A, Gallagher EJ.  Failure to validate the San Francisco Syncope rule in an independent emergency department population.  Ann Emerg Med 2008 August; 52(2); 151-159.

6. Rosen’s Emergency Medicine. Philadelphia: Mosby; 2010: 3-23, 142-148, 1333-1345, 1356-1366.

7.  Emergeny Medicine: A Comprehensive Study Guie.  McGraw-Hill; 2004: 108-118, 359-363, 1382-1389.

8.  Singer RJ, Ogilvy CS, Rordorf G.  Etiology, clinical manifestations, and diagnosis of aneurysmal subarachnoid hemorrhage.  Uptodate.com; 2010.

9.  McDermott D, Quinn J.  Approach to the adult patient with syncope in the emergency department.  Uptodate.com; 2010.

Intern Report Case Presentation 2.6

intern-report

Presented by Claire Jensen, MD

CC: “She passed out,” per EMS.

HPI: A 63 year-old African-American female presents to the emergency department by ambulance following a witnessed syncopal episode at a casino.  Upon her arrival in the ED, the majority of the history is obtained from EMS as the patient is actively vomiting.  She was seated at a slot machine with friends when she suddenly slumped to the floor unconscious.  She did not complain of feeling ill and was acting normally prior to the syncopal episode.  Within seconds of landing on the floor, she regained consciousness.  Initially she was somewhat slow to respond, but was alert and oriented, responding normally by the time the paramedics arrived.  She vomited once, and was transported to the ED.  A blood sugar was obtained in the field, 130 mg/dL.  Upon arrival, she complains of “just not feeling well” and continues to vomit.  She also complains of severe headache “all over” and some blurred vision. She denies vertigo, chest pain, shortness of breath or abdominal pain.

ROS: Negative except as mentioned in the HPI.

PMH: Denies.

PSH: Denies.

Medications: None.

Allergies: None known.

FH: Hypertension.

SH: Life-long non-smoker, non-drinker, and does not use illicit drugs.

PE:

VITAL SIGNS: BP 200/104, P 102, R 16, T 36.3, SpO2 99% on room air.

GENERAL: Alert and oriented x3, initially answers questions appropriately, diaphoretic, moderate distress from vomiting.

HEENT: Head is atraumatic, normocephalic.  Pupils are 2 mm bilaterally and minimally reactive to light.  Mild disconjugate gaze is noted, with slight temporal deviation of the left eye.  No nystagmus.  No conjunctival injection or pallor.  No scleral icterus.  Funduscopic exam attempted but unable to perform due to the patient’s continued vomiting.  Tympanic membranes are normal.  No nasal drainage.  Moist mucous membranes, no tonsillar enlargement.

NECK: Supple without lymphadenolpathy.  There is no nuchal rigidity, no carotid bruits.

CARDIOVASCULAR: Tachycardic, normal S1, S2, without murmurs, rubs or gallops.

RESPIRATORY: Lungs are clear to auscultation bilaterally.

GASTROINTESTINAL: Abdomen obese, soft, non-tender, non-distended, without masses or organomegaly.  Bowel sounds present.

MUSCULOSKELETAL: Normal muscle bulk and tone.  No deformities.  Unable to perform muscle strength testing due to patient’s decreasing ability to follow commands.  She moves all extremities spontaneously.  Peripheral pulses are 2+ and symmetric in all four extremities.

NEUROLOGIC: Unable to assess orientation due to patient’s continued vomiting, The patient is noted to have increasing difficulty following commands.  Disconjugate gaze as noted above.  The face is symmetric.  DTRs were not assessed.  Babinski is down-going bilaterally.

Near the completion of the physical exam, the patient suddenly became unresponsive with snoring respirations and minimal gag reflex.  IV access was obtained, and the decision was made to intubate the patient so that emergent CT scan of the head could be obtained.

Questions

1.  This is the patient’s CT (without contrast).  What is the diagnosis?

________

A.  Brain tumom

B.  Epidural hematoma

C.  Interparenchymal hemorrhage

D.  Subarachnoid hemorrhage

E.  Subdural hemorrhage

__________

2.  Which medication should be considered for use as an adjunct to rapid sequence induction in this patient?

A.  Atropine

B.  Defasciculating dose of vecurionium

C.  Fentanyl

D.  Ketamine

E.  Morphine

__________

3.  A 49 year-old man presents after he fainted while running on his treadmill at home.  He has been having exertional dyspnea and angina for the past several months.  Which of the following cardiac diseases is most likely to cause these symptoms.

A.  Aortic stenosis

B.  Atrial septal defect

C.  Mitral incompetence

D.  Pulmonary stenosis

E.  Tricuspid incompetence

______________

Please submit your answers to the questions in the “leave a reply” box or click on the “comments” link.  Your submission will not immediately post.  Answers with a case discussion will post on Friday.  If you have any difficulty, please contact the site administrator at arosh@med.wayne.edu. Thank you for participating in Receiving’s: Intern Report.

Intern Report Case Discussion 2.5

https://drhem.files.wordpress.com/2009/02/intern-report.jpg

Presented by Matt Steimle, MD

Chief complaint: “I can’t see”

28 year old female comes to the ER for loss of vision for 2 days, patient states that this happened suddenly after she was vomiting. Patient is 6.5 months pregnant and has hyperemesis gravidarum that has persisted through her entire pregnancy. She denies any eye pain and the vision has not improved. She says she is unable to see anything from the left eye. Previous to this she has not had any trouble with her vision, other than wearing reading glasses. She decided to come to the ER because her vision still has not improved. She has history of hypertension but no longer requires medication. Denies any headache, fever, chills, chest pain, palpitations, shortness of breath, abdominal pain diarrhea, constipation, dysuria, vaginal bleeding or discharge, no recent travel, no sick contacts.

ROS: negative except as noted per HPI.
PMH: Hx of Hypertension no longer on medication
Surg hx: none
Gyn: G1P0, good prenatal care
Meds: Prenatal vitamins
Allergies: Vicodin causes “throat to close”
FH: Hypertension and diabetes run in the family
SH: No tobacco/alcohol/drugs

PE: vitals: T 98.7, HR 76, BP 110/56, RR 18, pulse ox 100% RA, weight 231, 5’5’’
General: 28 year old, African American female, sitting converses without difficulty
Skin: No rashes or scars
Head: normocephalic, atraumatic
Eyes: EOMI, PERRLA constricting from 6 to 3 mm bilaterally with light, no afferent pupillary defects, Pt has 20/20 VA in right eye, left eye able to finger count correctly at 5 ft. In her left eye her vision is more clear in her peripheral fields than centrally, intraocular pressure R eye 12, L eye 13, peripheral fields are intact by confrontation, on fundoscopy there were no distinct optic discs visualized, no pallor, no icterus
Nose: symmetric, no discharge
Mouth, throat: No erythema or exudates
Neck: No tracheal deviation or masses
Heart: RRR, S1, S2 heard no murmurs rubs or gallops
Respiratory: CTA BIL
Abd: gravid uterus above the umbilicus consistent with 26 week gestation, soft NT ND,
CNS: Alert and oriented x 3, cranial nerves: II, III, IV, and VI see eye exam above, good eyelid opening bilaterally; V, corneal reflex intact bilaterally facial sensation intact bilaterally in V1,V2, V3, good jaw opening, and bite strength; VII, eyebrow raise, eyelid close, smile, frown, pucker, and taste all intact and equal bilaterally; VIII equal auditory acuity to finger rub bilaterally; IX good swallow reflex, positive gag reflex; XI good lateral head rotation, neck flexion, shoulder shrug bilaterally; XII midline tongue protrusion and equal strength on lateral deviation bilaterally. Equal strength in the upper and lower extremities bilaterally, speech and gait are normal.
Extremities: no peripheral edema, all peripheral pulses are felt, good range of motion, no weakness

Questions

1.  After you dilate the pupil this is your fundoscopic exam. Your diagnosis is?

_______________________________________________

A. acute glaucoma

B. vitreous hemorrhage

C. central retinal vascular occlusion

D. valsava retinopathy

E. central retinal vein occlusion

2. The patient should be advised which of the following?
A. use aspirin

B. sleep in a sitting position

C. decrease fiber intake

D. resume normal physical activity

E . all of the above

3.Which of the following are risk factors for the above diagnosis?
A.diabetes

B.hypertension

C.anemia

D. idiopathic thrombocytopenic purpura

E. all of the above

Answers:

1. D

2. B

3. E

Discussion:

This patient has a Valsava retinopathy. Immediately following a Valsava maneuver, a sudden rise in intraocular pressure causes retinal capillaries to spontaneously rupture. The prognosis for Valsava retinopathy is generally good.

Unilateral manifestations are most commonly seen, but bilateral findings have been reported. Sudden decreased vision occurs in the affected eyes, ranging from complaints of floating spots to complete loss of central vision. Vision often improves over weeks to months, depending on the severity of the retinal findings.

Risk factors for Valsava retinopathy are a history of vascular disease, diabetes, hypertension, sickle cell disease, anemia, idiopathic thrombocytopenic purpura.

Ocular findings are usually described as preretinal hemorrhages. Valsava retinopathy has a predilection for the macula. The ruptured vessels in the perifoveal capillaries usually cause a sudden and painless loss of central vision.
Causes: coughing, weight lifting, vomiting, bungee jumping, aerobic exercise, sexual activity, end-stage labor, colonoscopy procedures, constipation, and blowing musical instruments.

Medical care: patients should be advised to avoid anticoagulants and strenuous activities to prevent a rebleed. Patients should be instructed to sleep in a sitting position to promote blood settling, which may improve visual acuity, stool softeners may need to be considered for those with constipation. A diet rich in fiber is advisable. Physical activity should be limited until the retina has sufficiently healed. The patient should always try to limit activities that cause sudden increases in intrathoracic pressure against a closed glottis. Consultation to ophthalmology is recommended and needed for follow up.  Vision usually returns to normal over a short time period from weeks to months.

Key points:

  • When testing visual acuity use a Snellen chart at a distance of 20 feet or a Rosenbaum chart at a distance of 14 inches.  If the patient is unable to do this test visual acuity by testing  ability to count fingers (CF), if unable to do this test ability to perceive hand motion (HM), if unable to do this test  ability to perceive light (LP). The result may be recorded as “patient able to count fingers at 5 feet”
  • Acute angle-closure glaucoma: Pt has a narrow anterior chamber angle; folds of the peripheral iris can block the angle, which prevents aqueous humor outflow. The rapid elevation of intraocular pressure causes optic atrophy if not treated promptly. Patient often complains of nausea, vomiting, and pain. Emergent ophthalmologic consultation is indicated. Acute glaucoma is treated with IV mannitol or glycerol to decrease intraocular pressure by osmotic dieresis, topical miotics (i.e., 2% pilocarpine or 0.5% timolol) to decrease pupil size and increase aqueous outflow, and acetazolamide IV to decrease aqueous production
  • Vitreous hemorrhage: Suspect if sudden painless monocular loss of vision, more common in diabetics with an obscured red reflex and retinal details. Patients often report seeing flashing lights.  Patients also complain of seeing dark floating spots or floaters, which reflect benign vitreous separations
  • Central retinal artery and vein occlusion: both occur in middle-aged atherosclerotic patients or elderly hypertensive patients and present as sudden painless loss of vision. Occlusion of the retinal artery or its branches results in a dilated nonreactive pupil with an APD on the affected side. The retina is pale with a cherry-red spot on the macula. Occasionally amaurosis fugax precedes central retinal artery occlusion.
  • The fundoscopic examination of a central retinal vein occlusion is described as a “blood and thunder fundus” because of the presence of multiple large hemorrhages. Prognosis for both CRAO and CRVO is poor.

Common causes of nontraumatic loss of vision
Transient monocular
Amaurosis fugax
Temporal arteritis
Migraine

Persistent monocular

Central retinal artery occlusion
Central retinal vein occlusion
Retinal detachment or hemorrhage
Vitreous or macular hemorrhage
Optic or retrobulbar neuritis
Internal carotid occlusion

Acute binocular
Migraine
Vertebral basilar insufficiency
Cerebrovascular disease
Toxins (methanol, salicylates, quinine, ergot)
Optic or retrobulbar neuritis
Hysteria
Malingering

Sudden painless loss of vision

Central retinal artery occlusion
Central retinal vein occlusion
Vitreous hemorrhage
Retinal detachment
Ischemic optic neuropathy
Nonarteritic ischemic optic neuropathy
Valsava retinopathy
Functional visual loss, hysterical conversion or malingering

Retinal vein occlusion

______________________

Central retinal artery occlusion

___________________

Vitreous hemorrhage

_____________________

References:
1.Retinopathy, Valsalva, eMedicine http:emedicine.medscape.com/article/1228106
2.Emergency Medicine Secrets, fourth edition, 2006, pages 117-121, Markovchick
3.Rosen’s Emergency Medicine, seventh edition, 2010, pages 870-873, Marx
4.Uptodate, Approach to the adult with acute persistent vision loss, 2010, Leaveque
5.http://www.virginiaretina.org/pix/vitreous_hemorrhage.jpg, Virginia Retina Foundation

_______________________

This case discussion presented by Dr Matt Stemile

Intern Report Case Presentation 2.5

intern-report

presented by Matt Steimle, MD

Chief complaint: “I can’t see”

28 year old female comes to the ER for loss of vision for 2 days, patient states that this happened suddenly after she was vomiting. Patient is 6.5 months pregnant and has hyperemesis gravidarum that has persisted through her entire pregnancy. She denies any eye pain and the vision has not improved. She says she is unable to see anything from the left eye. Previous to this she has not had any trouble with her vision, other than wearing reading glasses. She decided to come to the ER because her vision still has not improved. She has history of hypertension but no longer requires medication. Denies any headache, fever, chills, chest pain, palpitations, shortness of breath, abdominal pain diarrhea, constipation, dysuria, vaginal bleeding or discharge, no recent travel, no sick contacts.

ROS: negative except as noted per HPI.
PMH: Hx of Hypertension no longer on medication
Surg hx: none
Gyn: G1P0, good prenatal care
Meds: Prenatal vitamins
Allergies: Vicodin causes “throat to close”
FH: Hypertension and diabetes run in the family
SH: No tobacco/alcohol/drugs

PE: vitals: T 98.7, HR 76, BP 110/56, RR 18, pulse ox 100% RA, weight 231, 5’5’’
General: 28 year old, African American female, sitting converses without difficulty
Skin: No rashes or scars
Head: normocephalic, atraumatic
Eyes: EOMI, PERRLA constricting from 6 to 3 mm bilaterally with light, no afferent pupillary defects, Pt has 20/20 VA in right eye, left eye able to finger count correctly at 5 ft. In her left eye her vision is more clear in her peripheral fields than centrally, intraocular pressure R eye 12, L eye 13, peripheral fields are intact by confrontation, on fundoscopy there were no distinct optic discs visualized, no pallor, no icterus
Nose: symmetric, no discharge
Mouth, throat: No erythema or exudates
Neck: No tracheal deviation or masses
Heart: RRR, S1, S2 heard no murmurs rubs or gallops
Respiratory: CTA BIL
Abd: gravid uterus above the umbilicus consistent with 26 week gestation, soft NT ND,
CNS: Alert and oriented x 3, cranial nerves: II, III, IV, and VI see eye exam above, good eyelid opening bilaterally; V, corneal reflex intact bilaterally facial sensation intact bilaterally in V1,V2, V3, good jaw opening, and bite strength; VII, eyebrow raise, eyelid close, smile, frown, pucker, and taste all intact and equal bilaterally; VIII equal auditory acuity to finger rub bilaterally; IX good swallow reflex, positive gag reflex; XI good lateral head rotation, neck flexion, shoulder shrug bilaterally; XII midline tongue protrusion and equal strength on lateral deviation bilaterally. Equal strength in the upper and lower extremities bilaterally, speech and gait are normal.
Extremities: no peripheral edema, all peripheral pulses are felt, good range of motion, no weakness

Questions

1.  After you dilate the pupil this is your fundoscopic exam. Your diagnosis is?

_______________________________________________

A. acute glaucoma

B. vitreous hemorrhage

C. central retinal vascular occlusion

D. valsava retinopathy

E. central retinal vein occlusion

2. The patient should be advised which of the following?
A. use aspirin

B. sleep in a sitting position

C. decrease fiber intake

D. resume normal physical activity

E . all of the above

3.Which of the following are risk factors for the above diagnosis?
A.diabetes

B.hypertension

C.anemia

D. idiopathic thrombocytopenic purpura

E. all of the above

Please submit your answers to the questions in the “leave a reply” box or click on the “comments” link.  Your submission will not immediately post.  Answers with a case discussion will post on Friday.  If you have any difficulty, please contact the site administrator at arosh@med.wayne.edu. Thank you for participating in Receiving’s: Intern Report.