Ophthalmology Emergencies Presenter ：莊海華 醫師 Supervisor：李景行 醫師 Moderator ：陳俊宇 醫師 2006/12/13(Wed)

Case 1 2006/12/13(Wed)

General Data Vital signs: 2006/11/08 10:15 姓名：彭xx 病歷號碼：2101xxxx 性別：男 出生：85年10月16日 年齡：10歲 主訴因車禍後視線異常 Vital signs: BT 36.2 ℃ HR 121/min RR 20/min BP 113/72 mmHg GCS:E4V5M6 2006/12/13(Wed)

Pediatric Assessment Triangle Appearance: fine Breathing: smooth Circulation: good 2006/12/13(Wed)

Chief Complaint Left eye upgaze and downgaze movement limitation after traffic accident 2 days ago 2006/12/13(Wed)

Present Illness Traffic accident (hit by a motorcycle) with left eye blunt injury Left eye persistent soreness and pain since then Left eye upgaze and downgaze limitation 2006/12/13(Wed)

Past and Personal History Drug allergy：nil Admission history：95/11/6-95/11/8 天晟 SAH and r/o orbital floor fracture 2006/12/13(Wed)

Physical Examination HEENT neck: no tenderness Chest breathing sound: clear heart sound: RHB, no cardiac murmur Abdomen soft and flat, no tenderness Extremity no edema, freely movable 2006/12/13(Wed)

Hemogram 951108 15:08 RBC:million/uL 5.16 WBC:1000/uL 8.2 951108 15:08 RBC:million/uL 5.16 Hemoglobin:g/dL 14.6 Hematocrit:% 41.7 MCV:fL 80.8 MCH:pg/Cell 28.3 MCHC:g/dL 35.0 RDW:% 12.1 Platelets:1000/uL 324 WBC:1000/uL 8.2 Segment:% 67.2 Lymphocyte:% 26.6 Monocyte:% 5.6 Eosinophil:% 0.4 Basophil:% 0.2 2006/12/13(Wed)

Biochemistry 951108 15:07 AST (GOT):U/L 16 ALT/GPT:U/L 14 Na:meq/L 140 951108 15:07 AST (GOT):U/L 16 ALT/GPT:U/L 14 Na:meq/L 140 K:meq/L 3.7 BUN (B):mg/dL 9 Creatinine(B):mg/dL 0.5 2006/12/13(Wed)

Ophthalmology Examination 2006/12/13(Wed)

CT of orbit 2006/12/13(Wed)

CT of orbit 2006/12/13(Wed)

CT of orbit 2006/11/08 Blow-out fracture of left orbital floor with herniation of inferior rectus muscle and orbital fat content Minor fractures at left inferior orbital rim and left maxillary sinus 2006/12/13(Wed)

CT of brain 2006/12/13(Wed)

CT of brain 2006/11/08 No intracranial hemorrhage Fracture of left orbital wall 2006/12/13(Wed)

Admission Course 2006/11/08 Surgery: repair of orbital floor, OS 2006/11/15 Discharge the patient Diagnosis at discharge: Orbital floor fracture with inferior rectus muscle incarceration, os Ocular blunt injury, os Principle Procedure: repair of orbital floor Out-patient-department follow-up 2006/12/13(Wed)

Key Points Trauma history + EOM limitation or diplopia -> orbital wall fracture 2006/12/13(Wed)

Case 2 2006/12/13(Wed)

General Data Vital signs: Saturation: 96% BW: 20kg 2006/11/23 20:30 姓名：陳xx 病歷號碼：8986xxx 性別：女 出生：89年4月27日 年齡：6歲 病患主訴因左眼皮膚潰瘍 Vital signs: BT 36.4 ℃ HR 126/min RR 22/min BP / mmHg GCS:E4V5M6 Saturation: 96% BW: 20kg 2006/12/13(Wed)

Pediatric Assessment Triangle Appearance: fine Breathing: smooth Circulation: good 2006/12/13(Wed)

Chief Complaint Left periorbital skin erosion noted for 2-3 days 2006/12/13(Wed)

Present Illness Left periorbital skin erosion for 2-3 days Left eye swelling today, itching(+), pain(-) No fever, no couhg, no rhinorrhea, no vomiting, no diarrhea Activity: fair, Appetite: fair 2006/12/13(Wed)

Past and Personal History Admission history: AGE, asthma, hand cellulitis Drug allergy: nil 2006/12/13(Wed)

Physical Examination General fair looking HEENT: left eye periorbital swelling, and erythema eyes: conjunctiva: not injected; sclera: not icteric mouth: no ulcer , mucosa: wet, no erythema throat: injected tonsil: no edematous 2006/12/13(Wed)

Physical Examination Chest: breathing sound: clear heart sound: RHB, no murmur Abdomen: soft and flat active bowel sound no tenderness 2006/12/13(Wed)

Hemogram 951123 22:44 RBC:million/uL 5.04 WBC:1000/uL 9.5 951123 22:44 RBC:million/uL 5.04 Hemoglobin:g/dL 13.1 Hematocrit:% 38.9 MCV:fL 77.2 MCH:pg/Cell 26.0 MCHC:g/dL 33.7 RDW:% 13.1 Platelets:1000/uL 252 WBC:1000/uL 9.5 Segment:% 47.9 Lymphocyte:% 36.5 Monocyte:% 5.7 Eosinophil:% 9.3 Basophil:% 0.6 2006/12/13(Wed)

Biochemistry 951123 23:00 CRP:mg/L < 0.5 2006/12/13(Wed)

Ophthalmology Examination 2006/12/13(Wed)

Ophthalmology Consultation Impression: Eyelid abrasion (OS) Pre-septal cellulites (OS) Conjunctivitis (OS) Suggestion: OSMD 1 GTT QID (OS) (眼內) Tetracyclin oph oint 1 GTT BID (OS) (眼外) Admitted to Ped and apply antibiotic 2006/12/13(Wed)

Admission course 2006/11/23 Admission with antibiotic use oxacillin 500mg/vial 1pc Q6H IVF sulfisomezole oph soln 4% 1GT QID tetracycline HCl 1% 1GT BID 2006/11/24 cefirizine and periactin 2006/11/27 Discharge the patient Out-patient-department follow-up 2006/12/13(Wed)

Key Point Differential diagnosis of preseptal cellulits and orbital cellulitis -> EOM limitation & diplopia 2006/12/13(Wed)

Case 3 2006/12/13(Wed)

General Data Vital signs: 年齡: 54歲 BT 36.5 ℃ 性別: 男 HR 121/min 已婚 2005-06-19 20:11 年齡: 54歲 性別: 男 已婚 職業: 水電工 檢傷三級 病患主訴：左眼睛痛 Vital signs: BT 36.5 ℃ HR 121/min RR 20/min BP 124/76 mmHg GCS: E4V5M6 2006/12/13(Wed)

Chief Complaint Left eye pain for 2 days 2006/12/13(Wed)

History and PE PI: N/V(-), no trauma (-) Left visual loss (+) Polydipsia x 2 days Transferred from 恩主公醫院 F/S 500 s/p RI 8U st Plt 21K Denied past Hx of DM Allergy: NKA Physical examination: Cons: E4V5M6 Neck: supple, free Chest: Breath sound: bilateral clear RHB Abdomen: soft and flat Pelvic/back: NP Extremities: free 2006/12/13(Wed)

Initial order 6/19 20: 43 (0hr 32 mins) F/S stat  268 mg/dl CBC/DC, BUN, Cr, ketone body, Blood osmo, Na, K, U/A, ALT IV with N/S run 120 ml/hr Consult Ophthalmologist 2006/12/13(Wed)

Ophthalmologist Consultation OD OS VA 0.6 Hand movement 5~10cm Pupil 25 mm round Mid-dilate L/R + - RAPD EOM Full and free IOP 15 mmHg 38, 39, 40 mmHg Lid/conj Slight inject Congestion Cornea Clear Edema, SPK(+) A/C Shallow/ Clear Shallow/ Blurred Lens NS+ Blurred F’d 2006/12/13(Wed)

Ophthalmologist Consultation IMP: acute angle closure glaucoma (OS) Suggestion: Mannitol (20%) 300 ml ivf st (check IOP 1hr later) Acetazolamide (250 mg) 2# PO st and 1# QID Pilocarpine 2% 1gt QID OS and st Carteolol 2% 1gt QID OS and st Prednisolone 1% 1gt QIH OS and st 2006/12/13(Wed)

6/19 Lab data BUN 15 Cr 0.9 Osmo 282 ALT 69 Na 131 K 4.0 Ketone (-) WBC 14200 Seg 81% Band 9% Lym 6% Mono 3% Meta-M 1% RBC 5.11 Hb 15.9 Hct 45.7 MCV 89.4 Plt 24000 BUN 15 Cr 0.9 Osmo 282 ALT 69 Na 131 K 4.0 Ketone (-) U/A Yellow/clear Sp gravity 1.010 pH 6.5 Nitrite Negative Protein 25 Glucose 1.0 Ketone 2+ Urobilinogen Bilirubin Blood 1+ Bacteria Positive WBC 6 RBC Epi 3 2006/12/13(Wed)

Follow up and Disposition Reduction of IOP (OS) from 45, 46 mmHg to 31, 32 mmHg ED Imp: (1) Acute angle closure glaucoma, OS (2) r/o DM (fresh case)  Well explain and OPD f/u on 6/20 2006/12/13(Wed)

More About Past History 1996/9: Left deep neck infection, s/p incision and drainage (Pus culture: Kleb. pneumoniae) 1997/11: Right deep neck infection, s/p incision and drainage (Pus culture: Aerobic bacteria growth) 1999/5: Right deep neck infection, s/p incision and drainage 1999/10: Left deep neck infection, s/p incision and drainage 2006/12/13(Wed)

Second ED Visit 6/20 15:34 T36.8, P 112, R 20, BP 96/65 E4V5M6 檢傷三級 病患主訴：L’t eye blindness for 2 days 2006/12/13(Wed)

History and PE PE: C.C: Blindness for 2 days Right eye redness Visual acuity: Left-blind, Right-intact Clear breath sound RHB, no murmurs Abdomen: Soft and flat, tenderness (-) Extremities: freely C.C: Blindness for 2 days PI: Eye pain (+) Blurred vision (+) Diplopia (-) Left headache (+) PH: DM (+), HTN (-), glaucoma(OS) 2006/12/13(Wed)

Consult ophthalmologist 6/20 15: 50 (0hr 16 mins) Consult ophthalmologist 2006/12/13(Wed)

Ophthalmologist Consultation OD OS VA 0.4 Hand movement 5 cm Pupil 25 mm round Mid-dilate L/R - RAPD EOM Full and free IOP 14 mmHg 6, 8, 9 mmHg Lid/conj Quiet Congestion cornea Clear Edema , SPK, ED 4*4mm A/C Shallow/ Clear Shallow/ Blurred Lens NS+ Blurred F’d No view 2006/12/13(Wed)

2006/12/13(Wed)

Ophthalmologist Consultation IMP: Acute glaucoma, OS Corneal erosion, OS Suggest: 1.Tobrex oint bid (OS) 2.pred-forte q2h (OS) 3.Carteolol bid (OS) 4.Analgesics 5.RTC on 6/21 2006/12/13(Wed)

Disposition 2005-06-20 17: 10 (1hr 36 mins) Medication Indomethacin (25 mg) 1# QID MgO (250 mg) 1# QID Tobramycin oph oint 1 gtt BID OU 餘青光眼藥水續用 Imp: Glaucoma (OS) Corneal abrasion (OS)  MBD and OPD f/u (at 6/21 PM) 2006/12/13(Wed)

Third ED Visit 6/21 15:52 (0 hr 0 mins) T38, P131, R 37, BP 105/69, E2V1M4 檢傷二級 病患主訴：SOB 2006/12/13(Wed)

History and PE CC: 在眼科OPD sudden onset SOB, then conscious drowsy PI: 前兩天是glaucoma (OS)來ER PH: DM (+) PE: (T38, P131, R 37, BP 105/69 E2V1M4) General appearance: clear? Neck: supple  stiffness Chest: clear BS, no wheezing Abdomen: tender (++); no guarding Other: NP 2006/12/13(Wed)

6/21 16:24 (0hr 33mins) CBC/DC, Cr, Na, K, ABG, Ketone, Osmo, Ck-MB, Tn-I, Amylase, Lipase, ALP, Bil(T), B/C F/S: 516 mg/dl  RI 10U iv stat Complete EKG, on EKG monitor, on pulse oximeter CXR, KUB O2 mask 35% N/S challenge 500 ml 2006/12/13(Wed)

6/21 CXR Multiple nodules 2006/12/13(Wed)

6/21 Lab data WBC 14700 Seg 88% Band 3% Lym 4% Mono At-lym 1% RBC 4.98 Hb 15.4 Hct 44.5 MCV 89.4 Plt 38000 Cr 1.2 Osmo (B) 314 ALT 56 ALP 182 Bil (T) 2.5 Na 133 K 3.8 Ketone 1+ Amylase 15 Lipase 32 CK-MB 0.4 Troponin-I <0.02 2006/12/13(Wed)

ABG data ABG pH 7.423 PaCO2 13.9 PaO2 97.5 HCO3 8.9 SBE -15.6 Sat% 97.8% 2006/12/13(Wed)

6/21 18:03 (2hr 12 mins) Obtain Brain CT (C-) 2006/12/13(Wed)

3 5 2 1 6 4 2006/12/13(Wed)

7 10 9 8 11 12 2006/12/13(Wed)

13 14 16 15 17 18 2006/12/13(Wed)

19 20 21 23 24 2006/12/13(Wed) 22

Report of brain CT 1. No definite intracranial hemorrhage or space-occupying lesion 2. Mild prominent sulci, fissures, and dilated ventricles 3. Atherosclerosis with wall calcification of the intracranial ICAs and VAs IMP: Mild brain atrophy and intracranial arteriosclerosis 2006/12/13(Wed)

6/21 19:47 (3hr 56 mins) Abdominal CT (C+/-) 2006/12/13(Wed)

Multiple lung nodules ( ) with cavitations ( ) 2006/12/13(Wed)

Hypodense hepatic lesions 5 2006/12/13(Wed) 6

Hypodense hepatic lesions: DDX: necrotic tumor, abscess, or Report of abdominal CT Lung nodules: metastasis is favored DDx- septic emboli, granulomatous vasculitis Hypodense hepatic lesions: DDX: necrotic tumor, abscess, or hemangiomas 2006/12/13(Wed)

6/21 20:38 (4 hr 47 mins) Arrange lumbar puncture 2006/12/13(Wed)

CSF data Xanthochromic (+), turbid 2+ WBC 1020 (N22/L1/M7), Protein 2+ Cell count WBC 1020 (N22/L1/M7), RBC 1840 (fresh : old = 59:41) Gram stain GNB 1+ Acid fast stain Negative India ink CSF Sugar/ blood sugar 33/516 CSF/plasma protein 413.1/4.5 Lactate (10.8-18.9) 171.1 Open/close pressure 20/8 cmH2O Cryptococcal antigen 2006/12/13(Wed)

Ophthalmologist Consultation OD OS VA Can’t check Pupil 25 mm round Blurred and haze L/R - RAPD EOM IOP 12 9,11 Lid/conj quiet SCH K clear Haze, blurred, central > peripheral A/C Shallow/ clear Shallow/ blurred Lens NS+ Blurred F’d No view Imp: glaucoma with medication (OS) Suggestion: 1.Hold oral medication 2.Hold brimonidine eye drop (due to CNS side effect) 3.先處理內科問題 4.OPD f/u or consult 3 days later (if admitted) 2006/12/13(Wed)

6/22 00:34 (8hr 43 mins) 6/22 01:55 (10hr 04 mins) E4V1M5 T 37.7, P134, R42, BP 139/72, CVP 6cm H2O, Sat 100% Persistent tachycardia, tachypnea and conscious disturbance Consult Chest (for ICU) at 01:04 (9hr 13mins) 6/22 01:55 (10hr 04 mins) Intubation and Admission to MICU 2006/12/13(Wed)

ER Diagnosis Severe sepsis Bacterial meningitis Multiple lung nodules, r/o septic emboli Liver nodules, r/o liver abscess R/O endophthalmitis, OS DKA 2006/12/13(Wed)

Key Point Endophthalmitis may mimic glaucoma 2006/12/13(Wed)