fun patient

[Bill_Brasky]

welp I was working the ER the other night and a women came in with a "migraine " headache that was the worst headache she ever had. Mildly photophobic, but no other symptoms and the distribution was all wrong, over her forehead bilaterally and running over top of her head to the nape of the neck. She had the headache for three days, which didn't respond to oxygen, triptans, and only mildly to narcs. Her BP was something like 190/112, though she had never had high BP before, and never had a headache like this before, though she had one real migraine in her entire life ten years ago which responded to normal treatment. The headache came on secondarily to a blow-out fight with her husband where she was crazily irrational (according to him ....and her ). CT was clean except for "mild chronic ischemic changes to the cerebellum." All other lab work was normal. We sent her home on narcs to ride it out.

I ran into her and her husband at Walmart three days later. She was buying reading glasses after her vision changed from 20/20 to 20/80 bilaterally in the space of two days. An MRI confirmed the cerebellar changes while showing no MS plaques. Her visit to the ophthalmologist didn't find any pathology. She has a neuro appointment coming up, but since this case was strange (at least to me) I thought I'd put it up here in hopes someone could illuminate what in the world was going on....

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[Bill_Brasky]

and I didn't find any focal or global neurological deficits in her, but then again I am an MS-III so take my exam for what it was worth.

 

[Nerdoscience]

Well, I would be worried about a small hemorrhage. They don't always show up on imaging. Was she tapped? Has she seen a Neruo-ophthalmologist about this visual change?

Also, she sounds crazy.

 

[Bill_Brasky]

Well, I would be worried about a small hemorrhage. They don't always show up on imaging. Was she tapped? Has she seen a Neruo-ophthalmologist about this visual change?

Also, she sounds crazy.

No tap unfortunately. I was ready to call her crazy too if not for the BP elevation.

 

[Pneumothorax]

Is it possible that some sort of hypertrophy of the pituitary gland or hypothalamus is there that was missed on the scans? An increase in ACTH could have something to do with the quasi-psychosis, and it could also possibly explain the deterioration in vision.

Does this make some sense? It is just a guess, from my semi-educated self, but...???

 

[NR117]

Buying over-the-counter reading glasses at Walmart? That means she did not get a prescription for glasses and probably has presbyopia. Is she in her late 40's, early 50's? If so, her age alone explains the need for reading glasses. It sounds to me like her distance vision did not change (otherwise she would be buying glasses at an optician, not Walmart), just her near vision.
If the ophthalmologist had found anything suspicious, he/she would have referred her to neuro-ophthalmology so I doubt there's anything really wrong with her vision.