Friday, December 27, 2013

Doctor, My Eyes...

In the ER you get all kinds of puzzles to solve.

The history is this:  A woman in her late 60s.  She tells me that while looking at her computer screen she developed a black spot in her central vision.  She looked away from the screen and then experienced a series of odd, glowing triangular shapes in both left and right visual fields, which slowly went over to just the left side, then faded away.

She also had a head ache and some chest pain, although on further questioning both these conditions seemed to have been present for weeks to months.


The patient did not seem to be in any distress.  In fact all her visual symptoms had resolved before her arrival in the ER, and the other symptoms seemed to be either ongoing or perhaps associated with a little anxiety after the visual symptoms.  She was concerned about retinal detachment.  She also suggested that the chest discomfort might be costochondritis.

Observation #1.
Patients who have diagnostic suggestions that specific often have a medical background. But that was not the case here.  In fact, I can generally detect active duty medical personnel at a range of 10 feet.  Retired doctors and nurses I can sense at roughly 50 feet.  The other possibility, as was the case here, is a person who looks a lot of stuff up on the internet.

Observation #2.
Since this involved both eyes there really could not be a local, one eye, problem like retinal detachment. It really had to be something central, in the vision processing areas of the brain.

Observation #3.
This being an ER after all, the words chest pain mean you get an EKG.  Should have been normal.  Totally was.

At this point with the patient cheerful and looking quite well I had to move on to other patients.  I sometimes do this when presented with a bit of a brain can process a few things on the back burner so to speak while doing other tasks.  Sometimes when you get back to the first patient in 10 or 15 minutes you have a theory.

My theory was that this might have been an atypical migraine.  It is very common to get bright geometric shapes as part of the "aura" or prelude to a migraine.  Sometimes the actual headache never turns up.  I tell patients it is sort of like singing the Star Spangled Banner and then not playing the ball game.  The other causes of transient, bilateral visual phenomena of this sort are much less common.  Seizure activity.  A concussion (no injury in this case).  And, er, well, not much else.

So I went back to the patient to put forward my theory.  She had something to tell me.

"I just remembered.  The internet site I was looking at when this all started was a collection of optical illusions!"

A new one for ER visit triggered by visual afterimages.

My job never wants for variety.

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