headache x 1 week

He'd be going with me to hospital.

I wouldn't be at all happy with someone leaving this pt at home.

I don't know whats wrong with him but I think he needs a CT head in the not too distant future.
 
Melclin said:
I don't know whats wrong with him but I think he needs a CT head in the not too distant future.
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Agreed.

At first read I'll admit I was leaning towards the "bull:censored::censored::censored::censored:" category but with other findings that popped up I'd be pressing hard to transport him. Also I'd be pushing pretty hard to get him into a room rather than triage.

I'm sure he'd probably be fine with an ILS transport but ALS would be better.
 
What is the most serious emergent condition that would cause his headache with unequal pupils. I did not know this myself, by the way.

Nope, it's not a bleed.
 
Herniation or acute glaucoma are probably the two that need the most immediate attention.
 
Acute glaucoma is another emergency condition I didn't consider.

Herniation from a bleed is sort of unlikely due to his normal mentation and the fact that the pupil has been dilated for a week, but I suppose it should not be ruled out.

A tumor is a definite concern, along with a whole bunch of other pathological causes for anisocoria, but it's not as emergent as something else that needs to be ruled out.
 
Something with one of the cranial nerves?
 
zzyzx said:
Acute glaucoma is another emergency condition I didn't consider.

Herniation from a bleed is sort of unlikely due to his normal mentation and the fact that the pupil has been dilated for a week, but I suppose it should not be ruled out.

A tumor is a definite concern, along with a whole bunch of other pathological causes for anisocoria, but it's not as emergent as something else that needs to be ruled out.
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When you look at his history of uncontrolled HTN resulting in hypertrophy and renal failure that makes him a pretty good candidate for intracranial hypertension, which I believe can lead to herniation in severe cases.
 
So, like I said I didn't consider this either, but the MD stated his main concern was that the unequal pupil + headache could be due to pressure from an aneurysm.
 
One Dx that is greatly overlooked is CSF leak. As him if his headache is worse while sitting up or standing up but better after laying down. Any orthostatic changes in pulse and BP? Is the pain in the eyes and stabbing, with a dull throb near the occipital lobe? Might be a CSF leak. Pretty rare but usually completely missed.
 
By the way, I don't know why this patient's pupil was not only dilated but also so oddly shaped.

I followed up on him and was told that his CT was unremarkable.
 
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