“I’m having a terrible headache.” The case of Madelyn Q. Chief Complaint: Headache Clinical History: Madelyn Q., a 50-year- and vomited in the toilet. Her daughter drove her to a local urgent care...

“I’m having a terrible headache.” The case of Madelyn Q.

Chief Complaint: Headache

Clinical History: Madelyn Q., a 50-year- and vomited in the toilet. Her daughter drove her to a local urgent care facility owned by a large community hospital. When the emergency physician questioned her about what led her to seek care, she said, “I’m having a terrible headache.” On further questioning, she revealed she was in general good health and active despite having Type II diabetes and hypertension. She developed Type II diabetes when she was 38 and began taking oral hypoglycemic agents for blood glucose control. Three years later, she was found to be hypertensive. Her BP was controlled by oral antihypertensives. She had worn glasses for reading since she was a child. She described the pain as severe, dull, and aching, and centered above her right eye. She also complained of excessive tearing and hazy vision in the right eye with “halos around all of the lights.” Physical Examination and Other Data: Madelyn was a well-groomed, poised woman who looked younger than her stated age. Vital signs were unremarkable, and physical exam revealed no abnormalities except for the right eye—there was mild scleral congestion, tearing, and the lids were slightly swollen. The right pupil was dilated and fixed. The left pupil reacted normally to light. Clinical Course: Concluding that she had an eye disease, possibly acute glaucoma, but unable to make a definitive diagnosis, the emergency physician made a referral to the emergency department of the parent hospital. A few days later, the emergency physician called the hospital, curious to know what had happened. A nurse in the ophthalmology department told him that the patient was diagnosed in the emergency room with acute closed-angle glaucoma. Records faxed from the hospital revealed that she was examined that evening by an ophthalmologist. Initial intraocular pressure in the right eye was 48 mm Hg (normal