Assessment

Case 1

A patient entered the examination room with a complaint of sudden-onset right-sided headaches X 1 week.  The clinician asked the patient whether the headaches seemed to get worse upon reading, which the patient denied.

Entering visual acuity, chair skills, and manifest refraction were unremarkable except for mild myopia OU.  The patient refused dilation, so a quick slit-lamp examination was performed with undilated 90D fundus evaluation, which was unremarkable.

The patient was given -1.00 DS OU spectacles.  The doctor recommended the patient take ibuprofen for his headaches, and see his regular doctor if they did not get better soon.

The entire examination took 20 minutes, start to finish.

One year later, the doctor received a notice from a lawyer that the doctor had missed the presentation of Horner’s syndrome, which, in this case, was caused by a malignant tumor.  Because of the delay in diagnosis (claimed as malpractice), the patient requested pain-and-suffering damages of $1,000,000.

Case 2

A patient entered the examination room with a complaint of sudden-onset right-sided headaches X 1 week.  Upon intense questioning, the patient revealed that the headaches were severe, and sometimes woke the patient from sleep.  The headache worsened upon bending over.

Entering visual acuity and manifest refraction were unremarkable. Chair skills were remarkable for subtle anisocoria (uneven pupil sizes), which increased under dim illumination.  The right pupil was smaller than the left.  Slit-lamp examination and dilated fundus examination were unremarkable.

The doctor diagnosed the patient with Horner’s syndrome, and referred him to a neurologist for an MRI.

Several weeks later, the neurologist sent back a report that described the presence of a tumor of the middle cranial fossa that was impacting the sympathetic nervous supply to the eye.  The tumor was removed and the patient was recovering nicely.