Emergency Med Case Challenge: A 41-Year-Old on Sildenafil With a Headache While Sleeping

Mousa Abujbara, MD


August 22, 2022

Physical Examination and Workup

Upon physical examination, the patient is ill-appearing but alert and in no apparent distress. His vital signs reveal a temperature of 103.1° F (39.5° C), a blood pressure of 155/95 mm Hg, and a pulse of 110 beats/min.

The ocular examination demonstrates ptosis of the right eye (Figure 1), which is deviated inferolaterally and has a dilated and unreactive pupil (Figure 2). The visual field examination demonstrates bitemporal hemianopsia. Funduscopic examination shows normal venous pulsation and mild bilateral temporal disc pallor.

Figure 1.

Figure 2.

The cranial nerves are otherwise without deficit. The neck is supple and without meningismus. Examination of the chest reveals mild bilateral gynecomastia, without nipple discharge. The lungs are clear to auscultation. Cardiac auscultation reveals a normal S1 and S2 and no murmurs, rubs, or gallops. The abdomen is soft and nontender, and no organomegaly is detected. Bilateral upper and lower extremity strength is 5/5, with normal deep tendon and plantar reflexes. The patient's sensation is intact to light touch and pinprick throughout, and the gait is normal.

Laboratory investigations reveal a hemoglobin concentration of 13 g/dL (reference range, 13.8-17.2 g/dL); a white blood cell (WBC) count of 16 × 103/µL (reference range, 4.5-11 × 103/µL), with 75% neutrophils; and a platelet count of 340 × 103/µL (reference range, 150-400 × 103/µL). The electrolyte, blood urea nitrogen, creatinine, and glucose levels are all within normal limits. Cerebrospinal fluid (CSF) specimens show 420,000 red blood cells/μL, 20,000 WBC/μL, a normal glucose of 85 mg/dL (4.72 mmol/L), and an elevated protein concentration of 230 mg/dL (2.3 g/L). The CSF Gram stain is negative for bacteria.

CT scan of the brain is performed, followed immediately by MRI (Figure 3).

Figure 3.


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