Case 9: Additional History and Physical Exam

Case 9 Index

Additional History:

The patient reports she has been struggling with the management of her migraines. She was on sumatriptan for a few months but after it failed to help, she discontinued it. Last week her neurologist prescrited topiramate 50 mg PO BID which she has been taking. She has also been taking fexofenadine for seasonal allergies, but denies any drug allergies.

Physical Exam: 

Vitals: Temp: 37C, BP: 110/70, HR 68, RR 12
VA without correction: 20/400 OU (can only see big “E” on chart)
Pupils: mid-dilated OU, reactivity: sluggish OU
Intraocular pressures (IOP) by tonopen: OD 38 mmHg, OS 32 mmHg
EOM: full
Confrontation Visual Fields (CVF): full OU

Below is an image of what you see on external exam:

shallow AC no PIExternal exam:
Eyelids: flat OU
Conjunctiva: mild injection OU
Cornea: Clear OU
Anterior Chamber: Shallow OU
Iris: flat OU
Lens: clear OU

Left Image Credit: CC BY-ND 4.0 


What’s at the top of your differential diagnosis? Choose 3 before moving on!
Undiagnosed primary open angle glaucoma
Acute angle closure glaucoma
Ocular migraine
Ocular hypertension
Secondary angle closure glaucoma

Given the patient’s elevated intraocular pressures and decreased vision, you call an urgent ophthalmology consult.

Click here for the ophtho exam!

Case 9 Index
Case 9 Introduction