AZCEP Posted April 21, 2006 Posted April 21, 2006 Optic nerve compression wouldn't cause the lack of movement, but might account for the lack of vision, right? The description of the onset of visual disturbance, going from the center of the field to the outside, made me think of a structural cause impinging the optic nerve. Don't know why that got stuck in my head, but there it is.
chbare Posted April 21, 2006 Posted April 21, 2006 ERDoc, conversion is a possibility,( but highly unlikely with the dilated pupils not being normal for the pt) but I am strongly considering other causes. There is no way this lady is going home. I am leaning toward some type of structural problem. Perhaps a small pituitary neoplasm putting pressure in all the right places, or perhaps a nasal/pharyngeal neoplasm not evident on the CT scan, or bilateral central retinal arterial occlusion. Hmmm, I will have to look into the possibility of a neoplasm. If the neoplasm is extracranial, (nasal/pharyngeal) this may mean mets. Take care, chbare.
ERDoc Posted April 21, 2006 Author Posted April 21, 2006 AZCEP, you are correct. The optic nerve (cranial nerve 2) is pure sensory providing info from the retina. The occulomotor nerve (cranial nerve 3) innervates most of the extraoccular muscles to allow the eye to move (cranial nerves 4 and 6 also provide some innervation). You have some good thoughts. chbare, your ambulance also has its own MRI (you work at a very progressive ambulance service ). The MRI is also negative. The husband says that when he returned he found the pill bottle empty and many pills spread throughout the house. He says it looks like she did not take all of her oxy and methadone. It appeared that the BP meds were taken appropriately. There were no qunine left, including the ones that were in the bottle in the cabinet. So, what do you think now?
AZCEP Posted April 21, 2006 Posted April 21, 2006 The fact that she is taking quinine is kind of odd, isn't it? Has she just returned from a trip overseas? Not much malaria in the U.S. is there? If this was a strictly quinine OD, there should be some ECG abnormalities as well. Seems that would happen well before the blindness.
chbare Posted April 21, 2006 Posted April 21, 2006 AZCEP, She is taking the quinine for leg cramps. I agree with your thinking, blindness by it's self is strange when thinking about quinine overdose. I would expect other S/S, HA, N/V, tinnitus, ECG changes, or hearing loss. We have ruled out most of the structural causes and intracranial causes from CT and MRI. Everything seems to keep pointing at quinine toxicity. Fundoscopy should show retinal artery spasm and disc pallor. (should have done this when I first suspected quinine toxicity and definitely when I got hold of the equipment producing fairy dust) Take care, chbare.
ERDoc Posted April 22, 2006 Author Posted April 22, 2006 Yup, this was quinine toxicity. The Ophthamologist didn't think she was ever going to regain her sight.
chbare Posted April 22, 2006 Posted April 22, 2006 Thank you for the scenario ERDoc. Take care everybody, chbare.
Ridryder 911 Posted April 22, 2006 Posted April 22, 2006 I thought it was quinine toxicity as well. I don't see quinine used as often as it was once used. Congrat's on the Dx. Chbare.. and the "thinker of a scenario " ERDoc as usual.. you made my brain hurt...LOL R/r 911
Callthemedic Posted April 22, 2006 Posted April 22, 2006 It makes me wonder why she would be so selective with the quinine. Did the "days of the week" sections not have raised letters? If they did, why did she ignore the other pills and gobble quinine? This thread gave me access to old minutiae in my A&P brain cells. This always happens when one of these scenario threads are up and I realize that it could take another turn. It went something like this: Quinine-malaria-sickle cell-hypoxia...........It was more of a side-street than the main road but at least it got me processing. Since I don't have a drug reference does anybody know a good online one? Thanks for the scenario, bring on another.
AZCEP Posted April 22, 2006 Posted April 22, 2006 Time to pull out the reference material again. I like rxlist.com for drug information. It can be tedious to keep track of all the new meds, but the ones that are listed are well described. I also do a daily update through ePocrates to my PDA. This gives all the newest FDA warnings about medications.
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