A 41-year-old military recruiter arrived at the clinic
complaining about vision loss. When he awoke that morning, he noticed mild
headaches and blurred vision in his left eye. A few minutes later he had no
peripheral vision. Within an hour of taking Ibuprofen 400 mg, his headache had
disappeared and his eyesight had improved. The patient felt good enough to go
to work, but a few hours later he noticed difficulties with his peripheral
vision on the right side. He did not report nausea or vomiting. In the past,
there were no headaches or blurred vision. The surgical history of the man included
thyroidectomy and tonsillectomy. The patient was currently taking levothyroxine
(Synthroid); He was allergic to penicillin.
1st exam
The patient was 5 feet 10 tall and weighed 214 pounds. The
vital signs included the temperature 97.7 ° F, the pulse 82 beats per minute
and the BP 118/83 mm Hg. His visual acuity on the Snellen eye chart was 20/40
right and 20/25 left. The students were equally round and responded equally to
light. Conjunctives were clear. The fundoscopy revealed clear disc margins and
showed no abnormalities of the blood vessels. The central vision in both eyes
and the peripheral view on the left were intact. However, the peripheral view
on the right side was reduced in the lateral, upper and lower areas. The
eardrum of the patient appeared to be normal. The cranial nerves were largely
intact. The deep tendon reflexes were equal bilaterally in the upper and lower
extremities. A Romberg test was negative.
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2. Diagnosis
My first impression was that a pituitary tumor caused
temporal hemianopia. I discussed the case with my co-operating physician, who
recommended consulting the ophthalmologist on call. Although I had decided that
the patient had to go to the emergency room for further processing, I called
the ophthalmologist. He agreed with my suggestion and recommended a trip to the
ED for an MRI, magnetic resonance angiography (MRA), complete blood count,
erythrocyte sedimentation rate, and a C-reactive protein. I discussed the plan
with the patient and informed the ED.
3. Unexpected findings
The ED physician found no other neurological deficits.
However, MRI revealed: (1) acute infarcts in the medial and posterior occipital
lobes, with minute infarcts in the deep left parietal and medial left temporal
lobes; (2) a more subacute to chronic infarction in the anterior medial right
occipital lobe; and (3) a chronic, tiny infarct in the right cerebellum. MRA
had an abnormal focal defect in the distal posterior cerebral artery.
The patient was admitted and started anticoagulation
therapy. During the hospitalization, he received a comprehensive work-up.
Carotid ultrasound was normal. The echocardiogram showed a low ejection
fraction of 45% to 50%, with a positive shunt from right to left being noted at
maturity. This eventually led to a transesophageal echocardiogram showing low
normal to mild left ventricular dysfunction in normal valves and a patented
foramen ovale (seen in 25% of the population).
Before discharge, the patient had no sensorimotor deficits.
His cognitive exam was unremarkable. At discharge, the only abnormal finding
was a visual field defect located mainly in the upper right quadrant. The
patient was released on warfarin (Coumadin) and advised to continue his life.
No surgery was recommended for his Foramen Ovale patent.
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