Who you are:
You are FY2 in Emergency Department or GP surgery.Who the patient is:
Mr. Brown is a 50-year-old man who presented with visual problems.
His wife has brought him. He has no significant past medical history.
Not on any medications and this is the first time you are seeing him.What you should do:
Assess the patient and discuss the management plan.
Background:
- 1⁄2 hour ago he scratched right side of my car by accident. He has no idea how he scratched his car
- A week ago, he broke the mirror on the left side.
- The accidents started happening two months ago.
- He has been driving for the last 30 years.
- Normally fit and well.
Focused history
- Explore main Concern
– Why did your wife ask you to come and see us?
– Why did your wife think you have a problem?
– What types of accidents have you had?
– Have you had any accidents at home?
– Have you bumped into things that are directly in front of you?
– Have you bumped into objects on your sides? - Associated symptoms:
– Are you able to see?
– Painful or Itchy or Discharge or Trauma
– Use of glasses
– Fever
DD’s
- Pituitary adenoma: Tunnel vision? Milky discharge from breast? Vomiting? Headache?
- Glaucoma
- Any injury to your head?
- Retinal detachment: Do you feel like a curtain came down suddenly and blocked your vision?
- Stroke: Facial weakness, Arm weakness, Slurred speech.
- Retinitis pigmentosa: Symptoms start in childhood, Impaired night vision, Progressive loss of peripheral vision (trip over things), May be loss in central vision which occurs later (late symptoms).
Past history + MMA
Occupation/ Driving
Psychosocial.
ICE
Patient preparation
- I will be examining your eyes to see why you are having these symptoms.
- I will check how far and good you can see and how well you see on your sides.
- Can you please take off your glasses/contact lenses (if the pt uses any).
- There will be a chaperone.
- May I proceed?
Examination:
Observation + Visual Acuity + Visual Field.
Visual Acuity
- We need Snellen’s Chart for this.
- We will do it from 6 meters away. Wait for the examiner to tell assume the distance.
- Tell the patient to close one eye and read all the letters starting from top.
- Repeat with theother eye. (in this pt visual acuity will be around 6/5 or 20/40 in both eye)
Visual Field:
-
We will be comparing patient’s visual field with our visual field.
-
Peripheral Vision
– We need White Head Pin for this.
– Please cover your left eye, I will also cover my left eye then I will make an imaginary X with this pin in front of you.
– Please keep looking at my nose. When you see the pin head from yourside, please node or say ‘yes’. Repeat with the other eye.
– Usually pt will not be able to see the head when moved from temporal side to central. That means, reduced peripheral vision or TUNNEL VISION. -
Central Vision
– Please cover your right eye for me and look at my nose.
– Is there any part of my face that is missing?
– Repeat with the other eye.
– You can use a Red Head Pin instead as well if it is provided.
Diagnosis
- I am afraid you have lost your side visions as you couldn’t see the white head of the pin when I moved it on your sides. This could be a cause of nerve damage responsible for your vision.
Management
- Immediate Referral to the hospital for admission under Brain and Gland specialist.
- Arrange an Ambulance.
- I suspect there is a compression on the optic nerve. Compression is commonly caused by a tumor in the brain called pituitary tumor. It isusually not cancerous, it is benign and if confirmed it can easily be removed by surgery, so no need to worry.
- However, we need to do some tests to confirm or exclude this Like MRI.
- Investigation: Routine bloods (All mainly prolactin level) + Urine + CXR
- Safety netting: Driving