Solve the Medical Riddle: She Has Had a Constant Headache for Two Weeks and Her Pupils Are Not the Same Size, First Week

Editor’s note: Welcome to our ThirdAge feature that gives you a chance to play medical sleuth as we share the details of what happened when a patient presented with a problem that stumped the physician at first.

We’ll start this week by letting you know what the patient told her PCP and how the doctor proceeded with the examination. Next week, the PCP and clinicians at the Emergency Department will continue to look for clues to the medical riddle. The third week, we’ll let you know what some people have suggested as possible diagnoses. The fourth week, the doctor will reveal the actual diagnosis. Then we’ll move on to a new riddle for the following month!

The Patient Reports Her Symptoms

Chloe, age 68, has had a constant headache for two weeks. It’s gradually getting worse and now the pupil of her right eye is bigger than the left one.


As always in ThirdAge Medical Riddles, the doctor uses the classic S-O-A-P notes as follows:

S=Symptoms or Chief Complaint

O=Objective Findings

A=Assessment or Analysis

P=Treatment Plan or Recommendations

This week, we’ll learn what Chloe told her PCP:

“I keep thinking this headache will go away, but I’ve had it for two weeks and it’s gradually getting worse. Then this morning when I looked in the mirror, I noticed that the pupil of my right eye is larger than the left one. The headache pain is mostly on right side of the top of my head so I wonder if the unequal pupil size is related. Frankly, I’m scared. I hope I don’t have a brain tumor! I’ve never been one to have headaches before this. I’ve never had a migraine. Why would I suddenly get this constant throbbing? I’ve tried to think of what could have caused it, but all I can come up with is the time about three weeks ago that I was visiting friends in New York City and I bumped my head when I was getting out of a cab. It was just a little bump, though, and it didn’t hurt much. I didn’t even take any aspirin or Advil. I felt fine. I hope you’ll tell me the headache is nothing and that it will go away on its own Still, I’m worried enough to want to get this checked out!”



Chloe’s physician was somewhat alarmed about the unequal pupil size and quickly zoned in on any other neurological symptoms in an effort to determine whether or not this was a medical emergency. During the Subjective part of the exam, the PCP asked about symptoms such as any change in mental status, slurred speech, sleepiness, confusion, vision blurriness, other vision changes, any gait or balance changes or leg or arm weakness, and any other subtle findings on one side of the body. She also asked whether Chloe’s headache is worse in morning or after sneezing, both of which can be symptoms that suggest increased intracranial pressure (pressure inside the skull).

Because Chloe is an older (but not elderly) woman, the doctor was concerned about the recent head trauma that had happened when Chloe got out of the taxi. Though admittedly a mild trauma, Chloe did recall the episode.

The PCP also noted that the patient is healthy with no chronic problems. Chloe takes only a multivitamin and vitamin D, she is not on blood thinners, is not a known alcoholic, and has no prior history of falls or head trauma. In addition, the doctor noted that Chloe is not a complainer and that she is reliable historian.


Chloe’s blood pressure and pulse were normal. Her general physical exam was also normal and she had no signs of bruising. The PCP moved on swiftly to a neurological exam. Chloe was alert, oriented, had no confusion, and her speech was fine. A cranial nerve exam revealed an abnormal third nerve on the right side. However, there was no ptosis (drooping of the eyelid), no asymmetric eye movement changes, and no double vision.

A check of her medical record and her last eye exam consultation with her ophthalmologist prior to the head bump incident showed no pupil asymmetry at that time. This worried the PCP.

The remainder of neurological exam including motor, sensory, and reflexes were all normal except for a subtle drift or weakness of her left hand when it was outstretched beside her right arm.


The sudden pupil change and subtle left arm weakness in the setting of new and unexplained headache in a 68-year-old woman was viewed with alarm by Chloe’s doctor as these symptoms demonstrate a new focal neurologic finding and constitute a medical urgency in this context.


Because of the potential medical emergency, the doctor transferred Chloe to the Emergency Department right away rather than referring her to specialist, which would have taken too much time if Chloe’s condition did indeed turn out to be an emergency . . .

To be continued . . .

Come back to next Thursday to learn what happened when Chloe first arrived at the Emergency Department . . .


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