An Active Duty Sailor With Worsening Headaches and Blurry Vision

Headaches are a typical presentation to a military medical department or emergency room. Having a broad differential diagnosis and utilizing a thorough physical exam can assist providers in honing down the list of pathology and in identifying potentially life-threatening causes of cephalgia such as intracranial tumors. In this case, a 27-year-old man presented with progressive headaches along with vision changes for the preceding 2-3 months. On initial physical exam, he was found to have bilateral papilledema using a panoptic ophthalmoscope, confirmed after sending the patient to optometry. Neurology evaluated him and found a pineoblastoma on MRI. He underwent eventual neurosurgical debulking and radiation. The highlight of this case is the critical history components along with physical exam techniques that can assist providers in the identification of life-threatening causes of a headache. Direct ophthalmoscopy was vital in this case to encourage referral for further management. In selected studies, emergency medicine providers performed ophthalmoscopy in 14% of patients, with roughly 10% of those patients having erroneous findings. Another study showed that 13% of all cases presenting to a large academic center had fundoscopic findings that were important to the final diagnosis.