Neuro-oph Case 2: Additional History and Physical Exam

Neuro-oph Case 2 Index

Additional History:

Three months ago, she went to student health services for worsening acne despite trying several treatments and was prescribed isotretinoin, which she now takes daily. Her only other medications include an oral contraceptive, ibuprofen as needed, and an albuterol inhaler, which she uses only a few times per year. Her family history is significant for migraines in her mother and sister.

Physical Exam: 

Vitals: Temp: 36.8C, BP: 123/82, HR 68, RR 14, BMI: 31 kg/m2
Neuro exam:
VA with correction: 20/20 OU
Pupils: equal and reactive OU, no rAPD OU
EOM: full OU, no nystagmus
Confrontation Visual Fields (CVF): visual fields intact to finger count in all 4 quadrants of both eyes
Remainder of the neurological exam is within normal limits

External ocular exam:
Eyelids: flat OU, no ptosis OU
Conjunctiva: white and quiet OU
Cornea: Clear OU
Anterior Chamber: Formed OU
Iris: flat OU
Lens: clear OU
Intraocular pressures (IOP) by tonopen in ED: OD 15 mmHg, OS 13 mmHg

Fundoscopic exam of the right eye reveals the following (the left eye exam appears the same):

Papilledema AAO

Above Image Credit: © 2020 American Academy of Ophthalmology

How would you describe the right fundus appearance?
Scattered hemorrhages throughout the macula
Diffuse retinal whitening with cherry red spot centrally
Optic disc swelling
Optic nerve cupping

What’s at the top of your differential diagnosis? Choose at least 3 before moving on!
Hypertensive emergency
Idiopathic Intracranial Hypertension (IIH)
Intracranial mass
Optic neuritis
Ischemic optic neuropathy
Meningitis
Migraine
Acute angle closure glaucoma

What would you like to do next?
MRI brain with MRV
Lumbar puncture
Lower blood pressure 
Check Hgb A1c 
Check CBC, ESR, and CRP 

Click here to move on!

Neuro-oph Case 2 Index

Neuro-oph Case 2: Introduction