A 16 year old obese female was admitted to the ICU with a severe headache and right sided weakness. Her blood work was within normal and the physical was unremarkable except for the right hand weakness. Because she was very obese and could not enter the MRI gantry, an image study of her brain was not done. Her vitals during the night are shown below. Her pulse oximetry at room air was 90% on room air. The CBC was 9, WBC 11, Na 134, K 5,0, Platelets 222, BUN 45, Cr 1.7, glucose 90 mg/dl and normal liver enzymes. She continued to remain hypertensive and later became confused. What is the next step in her management?
A. Arterial blood gas
B. Nuclear imaging study of her brain
C. Order a stat V/Q scan
D. Lumbar puncture
E. Hyperventilate
F. Start her on IV antihypertensive therapy
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Idiopathic intracranial hypertension (IIH) is a disorder of unknown etiology that predominantly affects obese women of childbearing age.
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The primary problem is chronically elevated intracranial pressure (ICP), and the most important neurologic manifestation is papilledema (see the image below), which may lead to secondary progressive optic atrophy, visual loss, and possible blindness.
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The other feature of this case is the CUSHING REFLEX- this is indicative of elevated intracranial pressure-Hope you did not miss it
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Patient needs urgent lowering of ICP and the first step is to intubate and hyperventilate. Next is mannitol.