jmj11 Posted December 18, 2011 Share Posted December 18, 2011 I ask the question again. I thought I was going to have a case to present, sudden onset of dementia in a 53 year old, but he got transferred before I had the chance and I've lost him to follow up. So, someone test us. Link to comment Share on other sites More sharing options...
physasst Posted December 18, 2011 Share Posted December 18, 2011 I ask the question again. I thought I was going to have a case to present, sudden onset of dementia in a 53 year old, but he got transferred before I had the chance and I've lost him to follow up. So, someone test us. Okay, but you aren't allowed to answer...:) 71 year old male with complaint of sudden partial loss of vision in the right eye that occured at 1 pm while working on a small woodworking project. He states that he had a curtain like loss of vision in the LOWER part of the eye that was dark gray in color. No associated symptoms. Became lighter gray over a period of five minutes and then he noticed some colors. Purple primarily, and had total symptom resolution within 15 minutes. Takes drops for chronic glaucoma, but has no pain. No headache. No temporal pain. Has a history of Ocular migraines, but states that those are different (his description is that of the classic scintillating scotoma) and that this was unlike any visual change he has ever had. Called his primary and sent in for exam. Exam: 71 yo male in NAD, PERRLA, anterior chamber clear, sclera, conjunctiva, and fundus are all clear and WNL. Right Eye: 20/60, Left Eye: 20/50. Pressures: Right Eye- 16....Left Eye- 18. Neurologic examination is completely benign.... PMH: Glaucoma Atypical Chest Pain Ocular Migraines HTN Diet controlled hypercholesterolemia What is it? Link to comment Share on other sites More sharing options...
mtg1111 Posted December 18, 2011 Share Posted December 18, 2011 Vitreous humour detachment? Link to comment Share on other sites More sharing options...
mtg1111 Posted December 18, 2011 Share Posted December 18, 2011 Or a BRVO? Link to comment Share on other sites More sharing options...
physasst Posted December 18, 2011 Share Posted December 18, 2011 Nope, neither of those. Link to comment Share on other sites More sharing options...
physasst Posted December 18, 2011 Share Posted December 18, 2011 Nope, neither of those.B BTW, this was a fast track patient...... Link to comment Share on other sites More sharing options...
jmj11 Posted December 18, 2011 Author Share Posted December 18, 2011 Okay, I won't try to solve it but I will ask some question, or statements . . . hmm . . . COMPLETE resolution in 15 minutes, that rules out a lot of things. Link to comment Share on other sites More sharing options...
deborah212 Posted December 19, 2011 Share Posted December 19, 2011 How about amaurosis fugax? Given his history of DM, HL, and HTN, would warrant carotid dopplers at least as an outpatient. Link to comment Share on other sites More sharing options...
physasst Posted December 19, 2011 Share Posted December 19, 2011 How about amaurosis fugax? Given his history of DM, HL, and HTN, would warrant carotid dopplers at least as an outpatient. DING DING, we have a winner......Now, let's add the fact that his symptoms started at 1 pm on a Friday, and he's in your urgent care at 4 pm... So what do you have to do now.......?????? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted December 19, 2011 Moderator Share Posted December 19, 2011 GET HIM ADMITTED AND RISK STARTIFIED BY NEURO...MRI/MRA WITH CONTRAST, ETC ( at least that's how we do it...obs admit with neuro consult). AF is basically a TIA so should be worked up as same as an inpt, not on an outpt basis. 5% of folks with a TIA have a cva within 24 hrs if not appropriately treated/anticoagulated, etc ps is he in afib? Link to comment Share on other sites More sharing options...
physasst Posted December 19, 2011 Share Posted December 19, 2011 Not necessarily, the recommendation is that a TIA workup has to be completed within 72 hours of symptom onset. During the week, we usually work these up as outpatients..but on a Friday, well, yep..... He spent 6.5 hours in Fast Track and had the whole workup done before dismissal.... Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted December 19, 2011 Moderator Share Posted December 19, 2011 Not necessarily, the recommendation is that a TIA workup has to be completed within 72 hours of symptom onset. During the week, we usually work these up as outpatients..but on a Friday, well, yep..... He spent 6.5 hours in Fast Track and had the whole workup done before dismissal.... my place is an interventional stroke ctr so they don't want these folks going home without the full meal deal workup( ct, carotid u/s, mri/mra, coag studies, etc, neuro consult, etc). sometimes we can get it done in the e.d. but they usually end up in our obs unit. Link to comment Share on other sites More sharing options...
jmj11 Posted December 19, 2011 Author Share Posted December 19, 2011 I've had a couple of these patients sent to me over the years as migraine aura. With his history, that would be tempting to conclude. However, monocular visual disturbance is extremely rare in migraine aura and if it does exist, it would be labeled "retinal aura," and it would only be a diagnosis after amaurosis fugax has been ruled out. Link to comment Share on other sites More sharing options...
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