A 23-Year-Old With Blindness After a Fall She Can't Remember

Jeffrey S. Forrest, MD; Alexander B. Shortridge

Disclosures

November 27, 2019

Physical Examination and Workup

The patient is 5'2" (1.57 m) and weighs 120 lb (54.43 kg). Her pulse is 80 beats/min. Her oxygen saturation is 95% on room air. Her respiration rate is 14 breaths/min, blood pressure is 128/84 mm Hg, and temperature is 98.3°F (36.8°C). The patient appears to be calm but also detached.

Ecchymosis is noted on the right side of her forehead from possible recent trauma. She is normocephalic. Her tympanic membranes appear normal. She has normal pupillary size and intact light reflex. Her visual acuity is 20/250 in her left eye (per Snellen chart test), whereas her visual acuity is 20/20 in her right eye. Optokinetic nystagmus is present.

No murmurs, rubs, or gallops are heard during cardiac evaluation. She has a regular heart rhythm. She displays a normal rate of breathing. Her lungs are clear to auscultation bilaterally. Her abdomen is nontender and tympanitic to percussion, with normal bowel sounds. She does not display facial droop, and her cranial nerves are otherwise intact. Hoover sign and Babinski reflex test results are negative. The patient cannot walk unaided upon gait evaluation. Muscle strength is 1/5 in her left lower extremity and 5/5 in all other extremities.

When giving her history, the patient acknowledged but downplayed the stresses her mother talked about. She said, "I can handle it." She reported no family history of mental illness. During a mental status evaluation, the patient appears alert and oriented to name, location, date, and time. She is appropriately groomed with good hygiene. Her behavior is detached. Her speech is soft, with slow responses of normal rate, rhythm, and prosody. Her thought process appears logical, linear, and goal oriented. She denies having any delusions, paranoia, or thought insertion/thought broadcasting.

She denies out-of-body experiences, although she agrees with the statement "the world feels like a dream." She continues to state, "I'm fine." As noted in her initial examination, the patient denied suicidal ideation, plans, gestures, or intention. Her affect is congruent with her mood; she has a blank, blunted appearance that conveys a distinct lack of concern. She answers questions appropriately. She is able to complete a serial sevens examination without errors and successfully recites the months of the year backward. She scores 3 for 3 on 3-item recall. Her recent and long-term memory is intact. Her insight appears poor, as she does not seem concerned about significant symptoms. The patient seems limited in her decision-making ability at present. When she was asked about proverbs such as "people who live in glass houses should not throw stones," she responded that it was a silly statement.

An EKG reveals normal findings. A CT scan of the head without contrast is performed and also reveals normal findings, with no evidence of cerebrovascular accident or mass lesions or bleeds (Figure).

Figure 1.

Urine toxicology screen results are negative. Urinalysis findings are within normal limits. Her complete blood cell count, comprehensive metabolic profile, and thyroid-stimulating hormone levels are all within reference range values.

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