Case 34: Vision loss

Opening scenario

Earl Griffin, a 66-year-old male, comes to the urgent care clinic because of vision loss.

Vital signs

• Temperature: 98°F (36.7°C)
• Blood pressure: 143/94 mm Hg
• Heart rate: 70/min
• Respirations: 17/min

Examinee tasks

• Take a focused history.
• Perform a relevant physical examination (do not perform corneal reflex, breast, pelvic/genitourinary, or rectal examinations).
• Explain the preliminary differential diagnoses and initial workup plan to the patient.
• Write the patient notes after leaving the room.

Patient instructions

• Act like you can see very little on the left side, where everything appears dark and blurry. If the examinee tests your left field of vision by asking you to look straight ahead and then holding his/her finger out to your left side and moving it slowly in front of your nose, pretend not to see the finger until it is almost in front of your nose.
• Use wrong words every now and then (e.g., “woman” instead of “wife” when asked about living arrangements) and pretend to have trouble finding the right words. Act frustrated when you make these mistakes.
• Pretend to have weakness in your right hand. When the examinee asks you to squeeze her/his hand, barely squeeze it. If she/he asks you to lift your right hand, barely lift it.
• Pretend to have decreased sensation in your right hand and lower right arm. When the examinee asks you if you can feel her/him touching you in those areas say “barely.”
• You are not aware of the meanings of medical terms (e.g., CT) and ask for clarification if the examinee uses them.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: Ask “Am I going to die?”

Hovering over the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form will not interrupt your progress.

History of present illness

• Chief complaint
• I cannot see out of my left eye.
• Onset
• It started about 2 hours ago.
• Constant/intermittent
• It has been like this the entire time.
• Precipitating events
• I do not remember anything special happening, no.
• Progression
• In the beginning, it felt like a veil over my eye that kept getting darker and darker. Now it has not changed for about an hour.
• Previous episodes
• I have had this before, yes. Maybe 5 or 6 times over the past 6 months. But it always went away after about 10 minutes.
• Frequency
• It maybe got a little bit more frequent. I think I had 2 episodes in the past 2 weeks.
• Alleviating factors
• None.
• Aggravating factors
• I do not think so.
• Associated symptoms
• I also have a headache.
  • Location
  • My entire head.
  • Intensity (on a scale from 0–10)
  • I would say a 4–5.
  • Quality
  • It feels like someone is squeezing my head.
  • Onset
  • I have had headaches on and off almost every other day for the past 8 months.
  • Precipitating events
  • Nothing that I can think of.
  • Progression/constant/intermittent
  • They have been really bad since they started.
  • Radiation
  • No.
  • Alleviating factors
  • Sometimes I take some ibuprofen.
  • Aggravating factors
  • Not really, no.

Review of systems specific to recurrent vision loss and headache

• Trauma
• No.
• Nausea/vomiting
• No.
• Fever/chills
• No.
• Night sweats
• No.
• Fatigue
• I am always tired. It comes with the age.
• Racing of the heart
• Yes, it is difficult to describe but sometimes it feel like my pulse does not have a normal rhythm.
• Rash/skin changes
• Not that I have noticed.
• Cough
• Yes, I have had a cough for the past 3 years, mostly in the mornings, though.
• Shortness of breath
• Sometimes, when I walk too fast.
• Urinary problems
• No
• Bowel problems
• No.
• Sleep problems
• I think I sleep alright, I usually get 6 or 7 hours per night.
• Appetite
• My appetite has seen better days.
• Weight changes
• No.
• Recent infections
• No.
• Dizziness
• No.
• Vertigo
• No.
• Falls
• Yes, once about 2 weeks ago. My right leg suddenly gave out on me and I fell.
• Weakness
• My right hand started to feel a little weak right before you came in.
• Numbness
• I do not think so.
• Tingling
• No.
• Seizure
• No.
• Problems speaking
• Not usually. I do not know what is wrong with me today. You must think I am stunned. I mean…stupid.

Past medical history, family history, and social history

• Past medical history
• I have high blood pressure and diabetes.
• Allergies
• None.
• Medications
• I take hydrochlorothiazide and metformin. And then ibuprofen for my headaches from time to time.
• Hospitalizations
• I had my appendix removed when I was in elementary school.
• Ill contacts
• No.
• Past surgical history
• Only my appendix.
• Family history
• My father died of lung cancer.
• Work
• I am a retired elementary school teacher.
• Home
• I live with my wife. My daughter and my 5-year-old granddaughter moved in with us about 8 months ago because she lost her job and is getting a divorce. It has been pure chaos. It is really no wonder that I always have a headache.
• Alcohol
• Only if we go out to dinner, maybe every other month.
• Recreational drugs
• Never.
• Tobacco
• Yes. I smoke about a pack a day. I think I started when I was 13.
• Exercise
• No, not really.
• Diet
• My wife cooks. We usually eat biscuits and gravy for breakfast, a sandwich for lunch, and some type of meat with beans, corn, or mashed potatoes for dinner.

• Washed hands
• Used respectful draping
• Head, eyes, ears, nose, and throat examination
  • Inspection of the head
  • Palpation of the head
  • Visual acuity evaluation (Snellen chart)
    • Low visual acuity (< 20/200) on the left
  • Direct fundoscopy
  • Visual field examination
    • Visual field deficit on the left
• Neck examination
  • Auscultation of the carotid arteries
• Cardiovascular examination
  • Palpation of the radial pulse
  • Auscultation of the heart
• Chest examination
  • Auscultation of the lungs
• Neurologic examination
  • Assessing level of consciousness
  • Examination of orientation to person, place, and time
  • Assessing speech
    • Motor aphasia
  • Focused examination of the cranial nerves
  • Kernig sign
  • Brudzinski sign
  • Meningism
  • Focused examination of passive and active motion
    • Muscle strength grading 1/5 in the right hand
  • Focused examination of sensation
    • Decreased sensation of the right hand and lower arm
  • Focused examination of deep tendon reflexes
  • Focused examination of gait
  • Rapid alternating movement test
  • Finger-to-nose test
  • Babinski sign
  • Romberg test

Patient interaction

• Examinee knocked on the door.
• Examinee introduced him- or herself and identified his/her role.
• Examinee correctly used the patient's name.
• Examinee asked open-ended questions.
• Examinee listened attentively (did not interrupt the patient).
• Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).
• Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).
• Examinee discussed initial diagnostic impressions with the patient.
• Examinee explained the management plan.
• Examinee used non-medical terms and provided reasons for planned steps in management.
• Examinee evaluated the patient's agreement with the next diagnostic steps.
• Examinee asked about concerns or questions.

Counseling and challenge

• Examinee reacted appropriately to challenge.

Suggested response to challenge: ”Mr. Griffin, I understand this must be a frightening experience for you, and I am glad that you came in to see me today. I will need to do a few tests and get some imaging done before I can tell you in more detail what is going on. However, I can promise you that you are in good hands, and that we are going to do everything in our power to take the very best care of you. If you would like to have a family member or a friend here for support, I would be happy to contact them for you. And if you have any questions or concerns while you are here, please make sure to let us know. It is important to us that you feel comfortable and informed. I also promise you that we will not take any steps that you do not agree with.”

Patient note

Differential diagnoses

1. Ischemic stroke: This patient has acute-onset focal neurological symptoms (L-sided vision loss, motor aphasia, R-sided hand weakness), which are highly suggestive of stroke. He also has multiple risk factors for stroke, including a history of smoking, hypertension, diabetes, and a possible atrial fibrillation, as well as the fact that he is > 65 years old and male. A carotid artery stenosis and resulting thromboembolism could cause decreased perfusion of the left ophthalmic artery (vision loss in the left eye) as well as the superior division of the left MCA (weakness of the left hand, sensory loss, aphasia).
2. Transient ischemic attack (TIA): While TIA is the likely cause of this patient's previous episodes of neurological symptoms, the duration of these current symptoms (2 hours and counting) should raise concern for stroke, since TIAs typically resolve after 1 hour (although per definition they can last up to 24 hours). Moreover, his symptoms are continuing to develop, with initial vision loss, then hand weakness and speech abnormalities starting around the time the examinee entered the room, and sensory loss appearing during the physical examination.
3. Intracranial neoplasm: Elderly patients with new-onset headaches should be evaluated for evidence of intracranial neoplasm, which in this case would also explain the patient's recent fatigue and loss of appetite. His smoking history and positive family history are risk factors for lung cancer, which can metastasize to the brain. However, intracranial neoplasm is only third on the list of differential diagnoses in this case because of the transience of the accompanying focal neurological symptoms up to now, which is more typical of TIA than a steadily growing intracranial neoplasm. The patient's home life changed drastically during the period when his headaches began, making tension headache a good alternative explanation for the new-onset headache.

Diagnostic studies

• Pulse oximetry: to rule out respiratory derangements as the cause of this patient's neurological deficits and assess oxygen status
• ECG and cardiac monitoring: to rule out atrial fibrillation as a cause of stroke and to assess for acute cardiac ischemia
• CBC: to assess for a potential platelet disorder and the likelihood of systemic infection (i.e., leukocytosis)
• PT, PTT: to assess whether the patient qualifies for fibrinolytic therapy and the likelihood of hemorrhagic stroke
• Electrolytes, serum glucose: to rule out hyper-/hypoglycemia and/or an electrolyte imbalance as the cause of this patient's neurological deficits
• Troponin: predicts neurological complications and outcome of stroke
• MRI brain: identifies ischemia earlier than CT; best imaging modality for determining soft tissue abnormalities and vascularity, as seen in intracranial neoplasms
• Noncontrast CT head: gold standard and most important initial imaging in suspected stroke

Other differential diagnoses to consider

• Migraine
• Intracerebral hemorrhage
• Subarachnoid hemorrhage
• Seizure disorders
• Meningitis
• See also headache and differential diagnosis of intracranial hemorrhage.