The First Case On an Unlucky Day

One fateful morning you find yourself in the Emegergency as the duty MO and by further push of luck the first patient you encounter is A 76-year-old female with a medical history significant for hypertension, hypothyroidism, hyperlipidemia and chronic renal insufficiency presented to the ED after fainting while hopping. She reported feeling light headed and dizzy while walking in a grocery store, at which time she experienced a brief loss of consciousness. She fell to the floor, bystanders called emergency services but she quickly regained consciousness. She denied head trauma or neck pain after the fall. She also denied chest pain but had been experiencing some shortness of breath with exertion over the past several weeks, as well as low back pain and bilateral thigh pain worse in the morning. She also noted gradually worsening vision in her right eye over the past week, increasing redness to that eye,and a mild, right-sided headache; her vision prior to this had been normal. Upon presentation to the ED, she could perceive light and vague shapes with the right eye. Her medcations included metoprolol, hydrochlorothiazide, Cozaar,evothyroxine, lovastatin and ibuprofen 400 mg orally twicedaily for low back pain.She denied tobacco use,drank alcoholoccasionally, lived alone and drove a car for transportation. You opt for PE and get the following information:


GENERAL APPEARANCE: The patient appeared well hydrated
and well nourished,and in no acute discomfort.

VITAL SIGNS
Temperature 98 F(36.6 C)
Pulse 54 beats/minute
Blood pressure 138/53 mmHg
Respirations 22 breaths/minute
Oxygen saturation 98% on room air
Visualacuity OS 20/50
OD light perception and hand
motion only (unable to count fingers)

Head Eyes & ENT: A traumatic, normocephalic,no afferent pupillary defect. Sclera of the right eye red and injected, no discharge. Tenderness to palpation over right forehead.No facial lesions or asymmetry noted.

NECK: Supple, no jugular venous distension.

CARDIOVASCULAR: Bradycardic rate, regular rhythm without
rubs,murmurs or gallops.

LUNGS: Clear to auscultation bilaterally.

ABDOMEN: Soft, nontender,nondistended.

RECTAL: Normal tone, brown stool,hemoccult negative.

EXTREMITIES: No clubbing,cyanosis or edema.

NEUROLOGIC: Visual acuity deficit of right eye (cranial nerve
II) as described;remaining neurologic examination nonfocal.

A peripheral intravenous line was placed and blood was drawn and sent forl aboratory testing. A12-lead ECG demonstrated sinus bradycardia ,rate56, without the presence of ST- T wave changes. A noncontrast CT of the brain was obtained (Figure given). Laboratory tests were significant for a leukocyte count of 12.6 K/µL with 81% neutrophils , hematocrit of 27% , creatinine of 1.7 mg/dL , (ESR) of 120 mm/hr and C-reactive protein (CRP) of 18.2 mg/dL

The electrolytes, glucose and troponin Iwere within normal limits ,and a urinalysis did not show signs
of infection.


What is your diagnosis ?

How are you going to manage it futher ?