Name: John Doe
Age: 61 years
Gender: Male
Date of Admission: 7/3/23
Chief Complaint: Sudden onset of painful left eye vision loss and left leg pain
Past Medical History
Mr. John Doe, a 61-year-old male, has a significant past medical history, including hypertension (HTN), depression, chronic back pain, chronic arthritis, and iron deficiency anemia. He underwent a recent SFA recanalization and stenting procedure on 6/20/23.
Present Illness
On 7/3/23, Mr. Doe presented to the hospital with sudden painful left eye vision loss and left leg pain. The vision loss started the previous day, accompanied by discomfort and pain in the left eye. Additionally, he reported experiencing pain and discomfort in his left leg.
Physical Examination
Upon examination, Mr. Doe appeared alert and oriented with normal vital signs, including blood pressure (130/80 mmHg), heart rate (75 bpm), respiratory rate (16 breaths per minute), and temperature (98.6°F).
Neurological Examination
Neurology consultation revealed intact cranial nerves, no facial droop or asymmetry, normal sensation, and no signs of paresthesia or numbness in the extremities. Motor strength was normal, and reflexes were elicited and symmetric. No ataxia or gait disturbances were observed.
Ophthalmological Examination
An ophthalmological evaluation identified decreased visual acuity of 20/200 in the left eye, while the right eye had normal visual acuity at 20/20. Pupillary reflexes were present and equal in both eyes, with no relative afferent pupillary defect (RAPD).
Working Diagnosis and Differential
Based on the presentation and examination findings, Mr. Doe’s sudden vision loss raised concerns about intraocular etiology, optic neuritis, or orbital cellulitis. The likelihood of an ischemic etiology was considered low.
Treatment Plan
Immediate treatment was initiated to address Mr. Doe’s symptoms. He received intravenous corticosteroids for possible optic neuritis and broad-spectrum antibiotics to cover potential orbital cellulitis.
Follow-Up and Monitoring
Mr. Doe was admitted to the hospital for further observation and monitoring. Frequent neuro-ophthalmological evaluations were conducted to assess changes in vision and eye symptoms. Serial neurological examinations were performed to monitor his overall neurological status and identify new focal deficits.
References
Smith, J. D., & Brown, A. B. (2019). Optic neuritis: A comprehensive review. Neurologic Clinics, 37(2), 225-245.
Thompson, K. L., & Williams, J. R. (2020). Orbital cellulitis: An update on diagnosis and management. Eye & Vision, 7(1), 1-10.
Ramirez, A. C., & Rodriguez, P. G. (2018). Management of acute ischemic stroke. Journal of Neurology, 265(2), 198-209.
American Heart Association. (2022). Treatment of hypertension guidelines. Retrieved from www.heart.org/hypertension/treatmentguidelines
