Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
Chief Complaint:
This section will vary depending on the severity of IIH. Common symptoms may include:
Headache (often described as dull, throbbing, worse in the morning)
Visual changes (blurring, dimming, blind spots)
Papilledema (swelling of the optic nerve) on funduscopic exam (performed by ophthalmologist)
Tinnitus (ringing in the ears)
Dizziness or vertigo
Back or neck pain (less common)
History of Present Illness:
Age at onset of symptoms
Duration and severity of symptoms (headache characteristics, visual changes)
Any recent changes in symptoms (worsening, new symptoms)
History of head trauma or other neurological conditions
Past Medical History:
Underlying medical conditions that can contribute to IIH (e.g., obesity, sleep apnea, polycystic ovary syndrome)
Prior surgeries or procedures (especially involving the head or spine)
Medication history (including current medications)
家族史 (jiā zú shǐ) Family History:
Family history of IIH (uncommon)
Social History:
Weight history (BMI calculation)
Sleep habits (presence of sleep apnea symptoms)
Use of alcohol or tobacco
Physical Examination:
Vital signs (blood pressure – consider ruling out secondary causes)
General appearance (signs of obesity)
Neurological exam:
Funduscopic exam by ophthalmologist (essential for diagnosis)
Visual field testing (may show deficits)
Assessment of cranial nerves (looking for signs of nerve palsies)
Meningeal signs (absent in IIH)
Laboratory Tests:
Blood tests may be done to rule out other causes:
Complete blood count (CBC)
Electrolytes
Thyroid function tests (TFTs)
Liver function tests (LFTs)
Infectious disease workup (if suspected)
Lumbar puncture (spinal tap):
Opening pressure is elevated in IIH (>250 cmH2O)
Cerebrospinal fluid (CSF) analysis (normal cell count and protein, decreased pressure after removing fluid)
Imaging Studies:
Magnetic resonance imaging (MRI) of the brain:
May be used to rule out other causes of papilledema (e.g., brain tumors)
Can show signs of increased intracranial pressure (ventricle size)
Magnetic resonance venography (MRV) of head and neck veins:
May be done to assess for venous sinus thrombosis (rare cause)
Diagnosis:
Idiopathic intracranial hypertension (based on clinical presentation, elevated opening pressure on lumbar puncture, and normal CSF analysis)
Consider ruling out secondary causes of intracranial hypertension.
Treatment Plan:
Weight management: Lifestyle modifications and/or medication for weight loss are crucial.
Diuretics: Medications like acetazolamide are the mainstay of treatment to decrease CSF production.
Optic nerve sheath fenestration (ONSF) surgery: Considered if vision worsens despite medical therapy.
Papilledema monitoring: Regular ophthalmology follow-up to monitor vision and optic nerve function.
Treating underlying conditions: If a secondary cause is identified, addressing that condition is essential.
Prognosis:
Discuss the outlook based on the severity of IIH, response to treatment, and weight management.
Early diagnosis and treatment are crucial to prevent vision loss. Long-term follow-up is essential to monitor vision and manage weight.
Patient Education:
Importance of weight management (diet, exercise)
Importance of medication adherence
Importance of regular follow-up appointments with neurology and ophthalmology
Importance of a healthy lifestyle (sleep hygiene)
Support groups and resources for patients with IIH
Next Follow-up: