Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

MKSAP: 64-year-old man with a new right-sided headache

mksap
Conditions
March 4, 2011
Share
Tweet
Share

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 64-year-old man is evaluated for a new right-sided headache that began 1 day ago. He awoke yesterday with a dull ache over his right forehead that has gradually increased in intensity. He also notes some right eye discomfort, sensitivity to light, and that his eye is red.

Vital signs are normal. The patient is uncomfortable and prefers to have the lights dimmed. Physical examination findings are shown. The right eye has diffusely injected conjunctiva and the cornea appears clear. The left eye is normal. The pupils are equal and reactive. Visual acuity is normal. Cranial nerves are intact.

Which of the following is the most likely diagnosis?

A: Herpes simplex virus keratitis
B: Herpes zoster ophthalmicus
C: Scleritis
D: Trigeminal neuralgia

Answer and critique

The correct answer is B: Herpes zoster ophthalmicus. This question can be found in MKSAP 15 in the General Internal Medicine section, item 104.

This patient has a localized headache associated with unilateral eye pain. There is conjunctival injection localized to same side of the headache and a skin eruption in the distribution of the first branch of the trigeminal nerve. This presentation is most consistent with a diagnosis of herpes zoster ophthalmicus. A zoster eruption in the first branch of the trigeminal nerve may involve the eye and cause blepharitis, conjunctivitis, keratitis, uveitis, ophthalmoplegia, or optic neuritis.

Herpes zoster ophthalmicus (which includes any involvement of the structures of the eye) is an ophthalmologic emergency, as it is potentially sight threatening. A particularly high-risk lesion is when zoster involves the tip of the nose, as this is the nasociliary branch of the trigeminal nerve and thus also innervates the cornea. All patients with a zoster eruption in the territory of the first branch of the trigeminal nerve should be emergently referred to an ophthalmologist to rule out eye involvement, even if only the skin appears to be involved, as deeper structures of the eye can be affected.

Herpes zoster ophthalmicus should be distinguished from herpes simplex virus (HSV) infection of the eye, which can cause inflammation and infection of the cornea (keratitis). HSV keratitis presents acutely with pain, blurred vision, and eye weeping; chemosis and conjunctivitis are present on physical examination. HSV keratitis differs from the conjunctivitis of herpes zoster in that it is not associated with a cutaneous eruption in a dermatomal pattern.

Scleritis is a painful, localized or diffuse, raised hyperemic lesion. Scleritis can cause deep, boring ocular pain but is not associated with a cutaneous eruption, making it an unlikely diagnosis for this patient.

Trigeminal neuralgia is typically characterized by excruciating, paroxysmal pain in the distribution of the trigeminal nerve. Although this patient’s pain was localized to the trigeminal region, the presence of a skin eruption makes this an unlikely diagnosis.

Key Point

  • Herpes zoster ophthalmicus is an ophthalmologic emergency and requires immediate referral to an ophthalmologist and institution of antiviral therapy.

Learn more about ACP’s MKSAP 15.

This content is excerpted from MKSAP 15 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 15 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to KevinMD.com on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

ADVERTISEMENT

Prev

Welcome our new (doctor) computer overlords

March 4, 2011 Kevin 10
…
Next

How the mobile internet can transform healthcare

March 5, 2011 Kevin 3
…

Tagged as: Specialist

Post navigation

< Previous Post
Welcome our new (doctor) computer overlords
Next Post >
How the mobile internet can transform healthcare

ADVERTISEMENT

More by mksap

  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 26-year-old man with back pain

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 36-year-old man with abdominal cramping, diarrhea, malaise, and nausea

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 52-year-old woman with osteoarthritis of the right hip

    mksap

More in Conditions

  • How President Biden’s cognitive health shapes political and legal trust

    Muhamad Aly Rifai, MD
  • The emotional first responders of aesthetic medicine

    Sarah White, APRN
  • Why testosterone matters more than you think in women’s health

    Andrea Caamano, MD
  • How veteran health care is being transformed by tech and teamwork

    Deborah Lafer Scher
  • What Elon Musk and Diddy reveal about the price of power

    Osmund Agbo, MD
  • Understanding depression beyond biology: the power of therapy and meaning

    Maire Daugharty, MD
  • Most Popular

  • Past Week

    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
    • How New Mexico became a malpractice lawsuit hotspot

      Patrick Hudson, MD | Physician
    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
    • Why health care leaders fail at execution—and how to fix it

      Dave Cummings, RN | Policy
    • How digital tools are reshaping the doctor-patient relationship

      Vineet Vishwanath | Tech
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
  • Past 6 Months

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
    • Why Medicaid cuts should alarm every doctor

      Ilan Shapiro, MD | Policy
  • Recent Posts

    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Decoding your medical bill: What those charges really mean

      Cheryl Spang | Finance
    • The emotional first responders of aesthetic medicine

      Sarah White, APRN | Conditions
    • Why testosterone matters more than you think in women’s health

      Andrea Caamano, MD | Conditions
    • A mind to guide the machine: Why physicians must help shape artificial intelligence in medicine

      Shanice Spence-Miller, MD | Tech
    • How subjective likability practices undermine Canada’s health workforce recruitment and retention

      Olumuyiwa Bamgbade, MD | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 3 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

  • Most Popular

  • Past Week

    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
    • How New Mexico became a malpractice lawsuit hotspot

      Patrick Hudson, MD | Physician
    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
    • Why health care leaders fail at execution—and how to fix it

      Dave Cummings, RN | Policy
    • How digital tools are reshaping the doctor-patient relationship

      Vineet Vishwanath | Tech
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
  • Past 6 Months

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
    • Why Medicaid cuts should alarm every doctor

      Ilan Shapiro, MD | Policy
  • Recent Posts

    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Decoding your medical bill: What those charges really mean

      Cheryl Spang | Finance
    • The emotional first responders of aesthetic medicine

      Sarah White, APRN | Conditions
    • Why testosterone matters more than you think in women’s health

      Andrea Caamano, MD | Conditions
    • A mind to guide the machine: Why physicians must help shape artificial intelligence in medicine

      Shanice Spence-Miller, MD | Tech
    • How subjective likability practices undermine Canada’s health workforce recruitment and retention

      Olumuyiwa Bamgbade, MD | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

MKSAP: 64-year-old man with a new right-sided headache
3 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...