Case History #189
Date of Admission: 8-15-2011
HISTORY
OF PRESENT ILLNESS:
This 52-year-old right-handed Hispanic female Spanish teacher presented
to the Emergency Department (ED) with a two week history of
intermittent, bilateral frontal and occipital headache associated with
photophobia, sonophobia, nausea, and vomiting. The patient
came to the ED one week ago for knee pain after a fall, and she was
given Norco for the pain. The medication exacerbated her
nausea and vomiting; so she returned to the ED a few days
later. A G-I evaluation was negative, and her pain medication
was changed to extra strength Tylenol. However, her headache,
nausea, and vomiting continued, and she once again returned to the
ED. This time a CT scan was obtained, and she was admitted to
the hospital for further evaluation.
Her neurological review of systems was entirely unremarkable, except
that the patient thought the vision in her right eye was somewhat
diminished. She denied any cognitive problems, numbness,
weakness, clumsiness, vertigo, diplopia, or any other neurological
symptoms. Likewise, her past medical history was unremarkable
and did not include hypertension, diabetes, hyperlipidemia, tobacco
use, or illicit drug use.
NEUROLOGICAL
EXAMINATION:
Mental
Status
Exam:
Intact.
Cranial
Nerves:
Sensation of smell was not tested. Visual acuity and
funduscopic examination were normal. Visual field testing
revealed difficulty seeing objects in the right half of the visual
field of each eye. Extraocular movements were full without
nystagmus or diplopia. Pupils were equal, round, and reactive
to light. Ptosis was not present in either eye.
Sensory and motor functions of the trigeminal nerves were normal
bilaterally. No facial weakness was present.
Hearing was intact bilaterally. Tongue and palate were normal
and midline. No weakness of XIth cranial nerve muscles was
present.
Motor
System:
There was no evidence of focal muscular atrophy or
fasciculations. Muscle tone and power were normal in all four
limbs. No involuntary movements were present.
Reflexes: Deep tendon reflexes were slightly brisker in the
right upper and lower limbs than the left. Plantar reflexes
were flexor bilaterally.
Sensory
System:
Sensory examination was normal
in all four limbs.
Cerebellar
Function:
All cerebellar tests were performed normally, including finger-to-nose
and heel-to-shin tests. No evidence of intention tremor, dysmetria, or dyssynergia was present.
Gait
and
Stance:
Regular and tandem gait were performed normally, and the Romberg test
was negative. The patient walked on her heels and toes
without difficulty.
Questions:
1. How would you
describe this patient’s visual findings?
2. Concerning her visual symptoms, indicate the specific
structures involved in producing these signs and symptoms. Is
there only one anatomical location that can produce these visual signs
and symptoms? If so, what is that location? If not, what
are the possible locations of such a lesion?
3. Considering her entire history and examination, what type of
pathologic process do you think is involved in this case?
4. What is the most likely pathologic diagnosis?
5. What diagnostic procedure(s) would you undertake at this point?
Answers
