Clinicopathological Conference: History and
Examination
East Medical Unit
05-05-2023
Presented by:
147. Suchna Meeral Khan
298. Salman Khalid
History
Our patient, Mr. Khalid Mehmood, aged 70 year, son of Mehtab Din, retired business owner
by profession, resident of Garhi Shahu, Lahore, presented in the OPD on April 27, 2023, with
the chief complaint of swelling around both eyes for the past one and a half year.
History of Presenting Illness
Our patient, diabetic and hypertensive, was in his usual state of health one and a half years
ago when he noticed swelling and redness around both his eyes. These symptoms appeared
gradually and have progressed variably over the past one and a half years with ongoing
treatment. The swelling was also accompanied by severe protrusion of the eyeball initially
before treatment, excessive teariness, as well as decreasing vision for the past one year. Our
patient reports feeling no grittiness, diplopia, or photophobia alongside his symptoms. The
swelling/redness was only relieved slightly with medical treatment, such as an eye lubricant.
There were no aggravating factors; however, the swelling increased or decreased variably at
different times of the day.
Mr. Khalid also reported a marked and progressive decrease in his vision six months into the
course of his illness (April, 2022). The decrease in vision was gradual in onset, and
increasingly severe in nature, such that he could not recognise faces from an arm’s length. It
was associated with poor color vision, and increased difficulty seeing in bright sunlight. His
vision tended to improve following steroid therapy, but always deteriorated again in a few
weeks. There were no aggravating factors. Our patient completely lost vision in his right eye
5 months ago.
Past Ocular History
Mr. Khalid reports very mild far-sightedness prior to disease, but has never worn glasses. He
was prescribed glasses during treatment of his illness. He has undergone surgery for cataract
in his left eye in February, 2023. He has no history of trauma.
Past Medical History
Our patient has suffered from constipation from a very young age; however, he reports
normal bowel habits ever since the start of this illness a year and a half ago. He was treated
for gastric ulcers approximately twenty-five years ago. He has had hypertension for the past
ten years, and his drug regimen includes amlodipine-valsartan (Extor 5 mg/80 mg) and
rosuvastatin (X-plendid). Mr. Khalid is also a known diabetic for the past five years, taking
only metformin irregularly for control. He reports suffering from long episodes of numbness
in his limbs twice or thrice a year, with a pins-and-needles sensation lasting two to three
hours and generalized lack of sensation lasting two to three days.
Past Surgical History
Our patient underwent ocular decompression surgery in June, 2022, angioplasty of the left
carotid artery in August 2022, and cataract surgery of the left eye in February, 2023.
Personal and Social History
Mr. Khalid is an ex-smoker with a history of 7.2 PY. He started smoking two to three
cigarettes a day in his youth and stopped one and a half years ago at the start of his illness. He
also regularly consumed paan twice a day and also stopped at the onset of his disease. He is a
retired business owner, now succeeded by his sons.
Family History
(?)
Treatment History
In February, 2022, approximately five months after disease onset, our patient was started on
IV glucocorticoid and carbimazole therapy. This resulted in reduced redness, swelling, and
slightly improved the patient’s vision. In June, 2022, ocular decompression surgery was
performed on the left eye with the aim to improve vision. The right eye was deemed non-
salvageable. Patient continued oral steroid therapy intermittently following the surgery.
Although the swelling and protrusion seem to have improved, no betterment was seen in the
patient’s vision.
Examination
An aged man of normal build is sitting at the edge of the bed, looking slightly exhausted is
well oriented in time, place and person . His pulse is (?) beats/minute, blood pressure
(?), temperature (?), and respiratory rate (?) /minute. There is no cyanosis, jaundice, clubbing,
Osler or Heberden’s nodes, palmar erythema, or splinter hemorrhages. Cervical lymph nodes
are not palpable. A vertical scar mark is present on the right side of the neck. The thyroid is
non-tender and not palpable; there is no bruit over the thyroid. The JVP is not raised. Sacral
and ankle edema is (?) present.
On ocular examination, direct and indirect consensual light reflexes are positive in both eyes.
Extraocular movements of both eyes are also normal. Bilateral proptosis is observed. The
visual acuity is of perception-of-light in the right eye and counting-fingers in the left eye.
Conjunctival congestion and chemosis is observed in both eyes, but it is more pronounced in
the left eye. There is pseudophakia of the left eye and cataract in the right eye. The fundus
can not be viewed in the right eye. The left disc is healthy with the Cup/Disc ratio of 0.3.
There is chorio-retinal atrophy of the right eye. The intraocular pressure is 31 mm of Hg in
the left eye. The intraocular pressure of the right eye could not be measured.
On cardiovascular system examination, pulse is (?) beats/minute, regular, no special
character, all the pulses are palpable, vessel walls are not palpable (?). On inspection of the
precordium, the apex is not visible (?). There is no pulsation or any prominent veins. On
palpation, the apex beat is palpable in the 5th intercostal space medial to midclavicular line.
No other thrill or parasternal heave (?) is palpable. On auscultation, the 1st and 2nd heart
sounds are of normal intensity.
On respiratory system examination, the shape of the chest is normal. The movement of the
chest with breathing is equal on both sides. There are no deformities, prominent veins, or scar
marks. On palpation the trachea is central, and vocal fremitus was normal and equal
bilaterally. Percussion is normal on both sides. On auscultation, breath sounds are of normal
intensity and vesicular in nature.
On nervous system examination, higher mental functions are normal. Speech is normal.
Hearing is bilaterally impaired; all communication was done at a raised volume. The cranial
nerve functions are intact. The motor system is intact as the patient is able to move all four
limbs. The sensory system is also intact as the patient responds to both touch and pain. Any
signs of meningeal irritation are absent.
