sachida
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A 23 yr old white female presents to a clinic with history of an episode of transient blindness 8 months ago. She describes complete loss of vision in her left eye for about a minute during taking a professional certification exam. She had no headache, palpitation or other symptoms before, during or after the episode. She then had another episode of agnosia in left upper quadrangle 2 weeks ago. Her past medical history is insignificant except occasional dysmanorrhea for which she was prescribed oral contraceptives. Her vitals are normal on examination. She describes her mental status as anxious and concerned. Her family history does not have any pertinent positive findings. She does not smoke and drink socially. Her physical systemic exam is completely normal.
1. What is the best initial test?
2. What is the best diagnostic test?
A. Hematocrait
B. Optometry and visual acuity
C. Echocardiogram
D. Platelet count and coagulation workup
E. Psychiatric evaluation
F. CT scan for head
3. What is the best therapy?
A. Aspirin
B. Warferin
C. Low molecular weight heparin
D. Vit B12 and folic acid
E. Do nothing refer it to phychiatrist
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| msyamp
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1coagulation study
2psychiatric evaalutin
3refer to psychiatry
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| AAAAA
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a group of 14 patients aged 8-38 years at presentation who had one or more sudden transient attacks of bilateral blindness. Eight patients described bilateral blindness as their only symptom whereas six others experienced some mild associated symptoms. Visual loss always developed within seconds and attacks were often precipitated by exercise, stress, or postural change. Of 13 patients available for review, none suffered a major vascular event during a mean follow up of 10 years. When adolescents and young adults present with transient bilateral blindness, investigations are unlikely to reveal a cause and the long-term prognosis appears benign
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| sachida
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I cant get any interpretation out of what AAAA posted. Can you please clarify.
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| AAAAA
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sachida wrote:
I cant get any interpretation out of what AAAA posted. Can you please clarify.
I just point out you can pull any papers and point to some answers.
But the correct answer will follow.
Thanks again.
I am just a student trying to learn too !
Thanks a million for reading my post.
In so many cases even in a tertiary center such as Mayo Clinic, up to 30-45% of many complaints went unanswered.
It means 40% of many complaints such as this question, the doctors would never find the real diagnosis of why the patient has transient blindness.
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| AAAAA
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sachida wrote:
A 23 yr old white female presents to a clinic with history of an episode of transient blindness 8 months ago. She describes complete loss of vision in her left eye for about a minute during taking a professional certification exam. She had no headache, palpitation or other symptoms before, during or after the episode. She then had another episode of agnosia in left upper quadrangle 2 weeks ago. Her past medical history is insignificant except occasional dysmanorrhea for which she was prescribed oral contraceptives. Her vitals are normal on examination. She describes her mental status as anxious and concerned. Her family history does not have any pertinent positive findings. She does not smoke and drink socially. Her physical systemic exam is completely normal.
1. What is the best initial test?
2. What is the best diagnostic test?
A. Hematocrait
B. Optometry and visual acuity
C. Echocardiogram
D. Platelet count and coagulation workup
E. Psychiatric evaluation
F. CT scan for head
3. What is the best therapy?
A. Aspirin
B. Warferin
C. Low molecular weight heparin
D. Vit B12 and folic acid
E. Do nothing refer it to phychiatrist
I took my Board exam just like this patient and actually had transient blindness at 11:30 a.m. I would NOT read any question in the last two pages and I knew I had hypoglycemia !
real life story !!
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| sachida
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Answers:
1. Echocardiogram
2. Platelet count and coagulation workup
3. LMWH
Explanations:
This patient is actually experiencing transient ischemic attacks due to hypercoagulation abnormalities and paradoxical emboli through patent foramen ovale.
Here are the clues why it is not psychotic or hypoglycemic events-
1. It happened twice. The second time it was not in environment suggestive of anxiety.
2. It resolved by itself. Hypoglycemia does not resolve by itself and those attacks happen more often in early mornings.
3. The present anxiety is due to repeated events. We will be too if it happened twice to ourselves
Here is why you should suspect emboli and hypercoagulation:
1. Nature of involvement - upper quandrange if you remember from step 1 optial radiation happens due to temporal lobe involvement.
2. She is taking OC pills
why echo should be done first
1. Rule out emboli from myxoma
2. Examine patient for persistent foramen ovale that can possible explain paradoxical emboli
3. If positive you can go on to workout reasons for emboli. If negative you are hardly left with other medical reasons that can explain transient blindness except psychiatric
Why platelet count and hypercoagulation workup
1. Mutations of factor V laiden and MHFTR are common in population. When present intogether they increase chances of emboli 10 fold. Platelet count was just a distraction
2. There is no point in doing this before looking at echo because if there was no right to left communication- the emboli should have caused Pulmonary embolism and there is no history of it in this patient
Why LMWH
1. Low molecular weight heparin should be given upon echo to prevent further emboli as well as ability to operate on Formen ovale.
2. You will add folic acid if homocysteine levels were high.
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| achilles
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good question and a very good explanation sachida. thanks.
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| AAAAA
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Dr. Sachida,
Excellent explantion.
But I just add my two cents from my own clinical experience.
I did have transient blindnesss at age 18. 19 ( I mean AAAAA) and my doctor did do the echocardioram which was negative.
They were suspecting small atrium septal defect or foramen ovale.
I underwent cardiac catherization the next day for "step-up oxygenation" in the right atrium if there was a small atrial septal defect or a physiologcal right-to-left shunt such as formen ovale.
An echocardiogram is not a 100% accurate to rule out foramen ovale.
I was doing research at National Cancer Instiute, Bestheda and the six floor at the Clinical Building (hospital) ws the cardiac cath lab. Luckily, everything turned out fine.
It is very interestin to point out the closing of small atrial septal defec will improve the migrane headache of many female patients with chronic migrane headache.
Kudu ! Just my own clinical experience.
(It is very interesting to look at medicine as a patient's viewpoint and understand and appreciate more why we have to study and take the examinations)
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| AAAAA
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Dietary supplementation with folic acid can reduce elevated homocysteine levels in most patients. The usual therapeutic dose is 1 mg/day. When this is not effective, vitamins B6 and/or B12 can be added to the regimen, which should be continued permanently. Some doctors routinely recommend that patients known to have atherosclerosis take B-vitamin supplements without being tested to determine whether their homocysteine level is elevated. They reason that since supplementation is harmless and since elevated homocysteine levels might be a factor, testing is not worth bothering with. Even though some patients may be helped with this "shotgun" strategy, I believe it is far better to (a) find out whether a problem exists and (b) to be certain that if homocysteine levels are elevated, the vitamin regimen is adjusted to be sure that lowering is achieved.
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