A fictional 52-year-old develops sudden severe headache, vomiting, ptosis and diplopia, followed by hypotension and reduced alertness.
Listen for the assumption.
The CT head was reported without subarachnoid haemorrhage, so I planned analgesia and observation.
The ocular palsy, visual risk and haemodynamic change suggest pituitary apoplexy. Draw endocrine samples if this causes no delay and treat suspected cortisol deficiency urgently.
I will arrange MRI and contact endocrinology and neurosurgery now.
Choose an answer below and reveal the reasoning to see consultant feedback at every checkpoint. The full consultant-led synthesis follows after all three decisions.
Go to the first decision ↓The picture develops.
- Acute severe headache with ocular motor palsy
- Hypotension and reduced consciousness
- Routine CT does not explain the syndrome
Commit before you reveal.
After you select an option, reveal the model reasoning and the consultant’s feedback.
Hear the senior team refine the plan.
The registrar tests the plan, the consultant synthesises the key principle, and the SHO confirms the safer next steps.
Document acuity, pupils, eye movements, visual fields where feasible, consciousness, sodium and haemodynamics.
Stabilise first, obtain the correct imaging and coordinate the endocrine-neurosurgical decision without serial handoffs causing delay.
I will make the visual and haemodynamic trajectory explicit at every review.
What must remain explicit.
- Use current Society for Endocrinology and local pituitary-apoplexy guidance.
- Do not delay emergency glucocorticoid treatment in an unstable patient.
- Record serial visual and neurological findings.
Where reasoning fails.
- Closing the diagnosis after routine CT
- Delayed glucocorticoid treatment
- Fragmented specialist referrals
Suspected pituitary apoplexy with onset [time], consciousness/haemodynamics [trend], ocular and visual findings [trend], endocrine samples/treatment [times], MRI [status] and specialist decision [owner].
Which team coordinates pituitary apoplexy out of hours in your hospital?