For Examiner Only
Case: Acute Glaucoma
Author: Lynne McCollough, MD
Reviewer: Douglas Char, MD
Approved: 2/113/06
ORAL CASE SUMMARY
CONTENT AREA
Ophthalmology
SYNOPSIS OF CASE
Elderly woman with acute onset of right-sided headache, visual disturbance, nausea and vomiting
due to glaucoma
SYNOPSIS OF HISTORY
1-hour history of severe right eye pain; symptoms occurring during the day. Had just come
outside from dark movie theater
SYNOPSIS OF PHYSICAL
Normal vitals except high BP, exam unremarkable except for classic findings associated with
acute angle closure glaucoma of the right eye exam when elicited.
CRITICAL ACTIONS
1)
2)
3)
4)
5)
Checking intraocular pressure
Making the diagnosis
Initiating appropriate therapy,
Consulting ophthalmology for definitive treatment
Provide pain and anti-emetic medications for comfort
SCORING GUIDELINES
(Critical Action No.)
1) Take off points if physician doesn’t check the IOP
2) Take off points if ophthalmology doesn’t come to the ED to see the patient.
FOR EXAMINER ONLY
For Examiner Only
PLAY OF CASE GUIDELINES
(Critical Action No.)
Pretty straightforward case of acute onset non traumatic right eye pain in elderly female. Onset after being
in the dark then coming in to the sun is significant No hx of trauma. There is no need to do the CT head or
get other ancillary tests but they are provided if the physician is doing a extensive work up and misses the
clues suggesting the need for measuring IOP nudge them back to task
FOR EXAMINER ONLY
For Examiner Only
Critical Actions
1.
Check intraocular pressure
This critical action is met by the candidate if they use Tonopen , Schiatz tonometer or
applination device to determine intraocular pressure
Cueing Guideline:
2.
Make diagnosis of acute angle closure glaucoma
This critical action is met by the candidate – tell patient dx and explain problem
Cueing Guideline:
3. Treat with topical β-blocker, pilocarpine, alphaagonist and steroid medications. IV therapy with
acetozolamide and mannitol should be considered, if
not initiated for such a severe case
This critical action is met by the candidate starting medications to reduce IOP
Cueing Guideline:
4. Emergent ophthalmology consult for definitive
treatment
This critical action is met by the candidate physician demanding that ophthalmology come
to the ED to see that patient
Cueing Guideline: “doctor they called back and said that they can see her tomorrow in the clinic”
5.
Symptomatic medications: anti-emetics, analgesics
This critical action is met by the candidate providing supportive medications
Cueing Guideline: “doctor she is still vomiting and says the pain is worse”
For Examiner Only
History Data Panel
Onset of Symptoms: Approximately 1 hour after leaving movie theater, she experienced
symptoms after walking outside from the darken theater into the afternoon sun. Severe right eye
pain
Description of Complaint: She was feeling well until she left movie theater, walked into the sun
(she forgot her dark glasses in the car). Patient developed frontal headache (right greater than
left), multiple episodes of nausea and vomiting. She also noted difficulty focusing on the
television. No history of similar symptoms, no fever, chills. Vague non-specific, mild abdominal
discomfort accompanied the nausea and vomiting. No diarrhea, no urinary symptoms.
Past Medical History
Surgical: appendectomy
Medical: HTN, DM
Injuries: (-)
Allergies: PCN
Habits
Smoking: ½ ppd
Drugs: (-)
Alcohol: social
Family Medical History
Father: NC
Mother: NC
Siblings: NC
Social History
Married: yes
Children: none
Employed: retired from real estate
Education: college
For Examiner Only
Physical Data Panel
Patient: 67-year-old woman
Patient Name: Gladys White
General Appearance: uncomfortable, appears fatigued, sitting up in bed dry heaving into emesis
basin, holding right eye-forehead
Vital Signs:
BP : 188/94
P : 94
R : 22
T : 37° C
Head: NCAT
Eyes: Bilateral conjunctival injection R>>L, 3 mm sluggishly reactive pupil, no discharge, steamy
cornea on the right. SLE otherwise normal
Ears: normal
Mouth: dentures, mucosa moist, no lesions, tongue not swollen
Neck: supple, no bruits, no JVP
Skin: no rash, cool, clammy
Chest: CTA bilaterally
Heart: RRR II/VI SEM, pulse +2 equal
Abdomen: soft, NT with active bowel sounds, no Murphy’s no McBurney’s
Extremities: well perfused, trace edema
Rectal: normal
Pelvic: N/A
Neurological: normal
Mental Status: normal
For Examiner Only
Case
Lab Data Panel
Stimulus #2 - Hematology
Complete Blood Count
WBC
8.5/mm3
Hgb
11.6g/dL
Hct
36%
Platelets
267/mm3
Differential
Segs
65%
Bands
0%
Lymphs
22%
Monos
10%
Eos
1%
Stimulus #5 –ECG LVH, no acute changes
Stimulus #6 –CT head (no acute changes)
VERBAL REPORTS
Tonopen R=64, L=38
Chest X ray – within normal limts
Stimulus #3 - Chem-7
Na+
K+
CO2
Cl-
137 mEq/L
4 mEq/L
104 mEq/L
22 mEq/L
Glucose
BUN
Creatinine
88 mg/dL
18 mg/dL
1.2 mg/dL
Stimulus #4 - Urinalysis
Color yellow
Sp gravity 1.010
Glucose - negative
Protein - trace
Ketone - negative
Leuk. Est. - negative
Nitrite - negative
WBC 2 / hpf
RBC 1 / hpf
KUB – within normal limits
For Examiner Only
Stimulus Inventory
#1
Emergency Admitting Form
#2
CBC
#3
BMP
#4
Urinalysis
#5
Tonopen results
#6
ECG
#7
CT head
FOR EXAMINER ONLY
Mock Oral Feedback Form – ABEM model
Date:
Examiner:
Examinee:
Data acquisition
Worst
1
NOTES
2
3
4
5
6
7
8
Best
Problem solving
Worst
1
NOTES
2
3
4
5
6
7
8
Best
Patient management
Worst
1
2
NOTES
3
4
5
6
7
8
Best
Resource utilization
Worst
1
2
NOTES
3
4
5
6
7
8
Best
Health care provided
Worst
1
2
NOTES
3
4
5
6
7
8
Best
4
5
6
7
8
Best
Comprehension of path physiology
Worst
1
2
3
4
NOTES
5
6
7
8
Best
Clinical competence (overall)
Worst
1
2
3
NOTES
5
6
7
8
Best
Patient Interpersonal relations
Worst
1
2
3
NOTES
4
Critical Actions
Dangerous actions
1.
Check intraocular pressure
 and omissions
2.
Diagnosis acute glaucoma based on hx and exam
 Penalty for delay in getting
3.
Initiate therapy to reduce IOP
 IOP, score down if
4.
Consult ophthamology

5.
Treat pain and vomiting

6.

7.

FOR EXAMINER ONLY
ophthalmology not requested
to come to the ED
Mock Oral Feedback Form – Core Competencies
Date:
Examiner:
Does not meet
expectations
Examinee:
Meets
Expectations
Exceeds
Expectations
1. Patient care
2. Medical
knowledge
3. Interpersonal
skills and
communication
4. Professionalism
5. Practice-based
learning and
improvement
6. Systems-based
practice
Critical Actions
Dangerous actions
1.
Check intraocular pressure
 and omissions
2.
Diagnosis acute glaucoma based on hx and exam
 Penalty for delay in getting
3.
Initiate therapy to reduce IOP
 IOP, score down if
4.
Consult ophthamology

5.
Treat pain and vomiting

6.

7.

FOR EXAMINER ONLY
ophthalmology not requested
to come to the ED
Stimulus #1
ABEM General Hospital
Emergency Admitting Form
Name
Gladys White
Age
68
Sex
Female
Method of Transportation ambulance
Person giving information
Presenting complaint
patient
vomiting and headache
Background: Patient has been otherwise well up until presentation. She ate
refrigerated leftovers for lunch. She had just finished seeing a movie with her husband.
She had the abrupt onset of symptoms.
Vital Signs
BP : 175/88
P
: 90
R
: 22
T
: 37.2° C
Stimulus #2 - Hematology
Complete Blood Count
WBC
8.5/mm3
Hgb
11.6g/dL
Hct
36%
Platelets
267/mm3
Differential
Segs
65%
Bands
0%
Lymphs
22%
Monos
10%
Eos
1%
Stimulus #3 - Chem-7
Na+
K+
CO2
Cl-
137 mEq/L
4 mEq/L
104 mEq/L
22 mEq/L
Glucose
BUN
Creatinine
88 mg/dL
18 mg/dL
1.2 mg/dL
Stimulus #4 - Urinalysis
Color yellow
Sp gravity 1.010
Glucose - negative
Protein - trace
Ketone - negative
Leuk. Est. - negative
Nitrite - negative
WBC 2 / hpf
RBC 1 / hpf
Stimulus # 5 ECG
Stimulus # 6 CT head
radiology reading : no acute findiings