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A 17-year-old high school student is admitted to the hospital for treatment of anxiety disorder when he reports acute loss of vision in the left eye. His past medical history is significant for intractable anxiety disorder for the past 3 years. Physical examination reveals bilateral proptosis. There is no vision in the left eye and vision in the right eye is normal. Extraocular movements are intact bilaterally. The sinuses and ears are normal on exam. An MRI of the brain is urgently performed and is normal. Recent laboratory studies show:
sodium-135
potassium-3.7
Cr-1.0
WBC-2200
Hct-42%
Plt-270
TSH-0.3microunit/litre
The next step is
A. buspirone administration
B. coumadin administration
C. diazepam administration
D. EEG
E. funduscopic examination
F. heparin administration
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The correct answer is E. This patient's symptoms of anxiety, bilateral proptosis, and a decreased thyroid stimulating hormone (TSH) are consistent with hyperthyroidism with thyroid ophthalmopathy. A thorough funduscopic exam will reveal papilledema. An uncommon complication of thyroid ophthalmopathy (5% of cases) is optic neuropathy from edema of the extraocular muscles with secondary compression of the optic nerve.
Anxiolytic therapy with buspirone (choice A) may be necessary, but treatment of the underlying hyperthyroidism is the primary clinical concern. The next most appropriate step is to perform a thorough funduscopic examination to evaluate for papilledema.
Anticoagulation (choice B) is not necessary. This patient is suffering from optic nerve compression secondary to extraocular muscle edema, not a stroke.
Anxiolytic therapy with diazepam (choice C) may be necessary, but treatment of the underlying hyperthyroidism is the primary clinical concern.
Vision loss is a rare complication of a seizure which could be evaluated by EEG (choice D). Seizure as a cause of vision loss is an unlikely possibility given that this patient has anxiety, bilateral proptosis, and an elevated thyroid stimulating hormone (TSH). These findings are all consistent with hyperthyroidism and secondary thyroid ophthalmopathy.
Anticoagulation with heparin (choice F) is not necessary. This patient is suffering from optic nerve compression secondary to extraocular muscle edema, not a stroke.
