Mock 11

Addressing a patient presenting with symptoms suggestive of bitemporal hemianopia involves a focused approach to identify the underlying cause and manage accordingly. This clinical scenario will help IMGs (International Medical Graduates) understand how to handle this complex presentation effectively:

Clinical Scenario: Suspected Bitemporal Hemianopia

Where You Are: Ophthalmology Clinic

Who the Patient Is: A 58-year-old male, Mr. Michael Anderson

Other Information About the Patient: Mr. Anderson has been increasingly bumping into objects, especially noticing issues with peripheral vision. His wife is concerned about his vision changes and accompanied him to the appointment.

Patient Prompts

• Onset: "I started noticing issues a few months ago, but it's gotten worse recently."
• Duration: Gradually worsening over the past several months.
• Progression: "It's becoming more difficult to navigate, especially in crowded places."
• Aggravating Factors: "It's worse in low-light conditions."
• Relieving Factors: "Not really anything; maybe when I focus straight ahead, it feels a bit better."
• Past Medical History: Hypertension, controlled with medication.
• Regular Medications: Lisinopril.
• Allergies: No known allergies.
• Smoking and Alcohol Intake: Non-smoker, occasional alcohol.
• Use of Recreational Drugs: Denies use.
• Occupational History: Accountant.
• Simulated Examination Findings: Visual field testing indicates loss of vision in the outer half of both the right and left visual fields. Normal anterior segment examination, intraocular pressure within normal limits.

Scenario Clinchers

• Patient Concerns: Increasing difficulty with navigation and daily activities; his wife is very worried about his safety.
• Clinchers and Important Points for the Doctors: The pattern of vision loss is consistent with bitemporal hemianopia, often associated with lesions affecting the optic chiasm.

What You Must Do:

• Immediate Actions:
  • Reassure the patient and his wife about the steps for further evaluation.
  • Explain the importance of identifying the underlying cause of the visual field loss.
• Diagnostic Steps:
  • Refer for neuroimaging, specifically MRI of the brain, to evaluate the optic chiasm and surrounding structures.
  • Consider blood tests to assess pituitary function if a pituitary adenoma is suspected.
• Referral to Specialists:
  • Refer to a neurologist or neuro-ophthalmologist for further evaluation and management based on the MRI results.

Differential Diagnosis

• Pituitary adenoma
• Craniopharyngioma
• Meningioma
• Stroke affecting the optic pathway

Typical Question to Rule Out Differentials: "Have you experienced any other symptoms like headaches, changes in smell or taste, or any hormonal imbalances that might indicate a pituitary issue?"

Red Flags

• Rapid progression of visual field loss.
• Associated symptoms such as headache, nausea, or vomiting.

Actions Doctor Should Do

• Conduct thorough visual field testing to confirm the pattern of vision loss.
• Order immediate neuroimaging to investigate potential causes.
• Assess for other neurological symptoms that may guide further diagnostic testing.

Referral Needs

• Type of Referral: Urgent referral to neurology or neuro-ophthalmology.
• Reason for Referral: Evaluation and management of potential central nervous system pathology causing the bitemporal hemianopia, which may require urgent intervention.

This structured approach ensures a comprehensive evaluation of a patient with suspected bitemporal hemianopia, prioritizing immediate diagnostic steps and specialist referrals to address this potentially serious condition.