Quick Thinking Part 2

April 6, 2007

ThinkerWelcome to Quick Thinking a new feature of Clinical Correlations. A case will be presented in short sections to a faculty expert who will comment on their approach to the patient as the case unfolds. These posts will focus on the thought process involved in determining the initial differential diagnoses and diagnostic workups of complicated patient presentations.

Part 1 can be found here.

Part 2 of Case Presentation By:Elizabeth Ross PGY-3

He was originally seen at Elmhurst Hospital and transferred to Bellevue Hospital.  On presentation to Bellevue Hospital he was admitted to the neurology service and his exam was as follows:

General: overweight African American male, alert and fully oriented, conversant
vital signs:  temperature 101.5, blood pressure-120/60, Pulse-100, Respiratory Rate 18
HEENT: pupils equal round reactive to light and accommodation, oropharynx benign
Heart: rate rhythm regular,normal S1 S2 without s3s4, no murmurs rubs or gallops,
Lungs: clear to auscultation and percussion bilaterally
Abdomen: soft, non-tender, non-distended, no hepatosplenomegaly
Extremities: no clubbing, cyanosis or edema
Neurologic: +right afferent papillary defect, decreased peripheral vision on right.  otherwise intact
Gentio-urinary: no testicular masses, nodules

Commentary: Mitchell Charap, MD Abraham Sunshine Associate Professor of Medicine

The remarkable aspects of the physical exam include fever and temporal visual field  cut/afferent pupillary defect. The former suggests infection or other disorders that result in fever, specifically here, lymphoma. The latter suggests a process involving (injurying) the optic nerve. Anatomically  a mass in the suprasellar area can result in  such findings. Although tuberculosis and fungal infections can affect the cranial nerves; the defect in the optic nerve suggests a mass, not diffuse meningeal involvement.  I am surprised that the patient is overweight – he must have been obese (or not telling us the  truth) three months ago.

To Be Continued…

One comment on “Quick Thinking Part 2

  • Avatar of Y. Kong
    Y. Kong on

    Given his presentation of fever, unilateral visual changes and headache, is vasculitis a possible differential? Even though temporal arteritis is rare in patients under 50, I would be curious to know if patient had other signs and symptoms such as jaw claudication or temporal artery tenderness.

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