Ambulatory Report Pearls 6.28.17

Thank you Julia Janssen for presenting your first week of intern year!  We had the case of a 56 yo F pmhx of HTN, alcohol use disorder presenting with chronic facial and sinus pain found to have homonymous hemianopsia from an old stroke. 
Diagnostic Criteria for Chronic Sinusitis
  • To meet the definition of sinusitis you need both symptoms AND documented radiographic or nasoscopic inflammation
    • Symptoms for >12 weeks
    • Two or more of the following symptoms:
      • Mucopurulent discharge (anterior, posterior, both)
      • Nasal obstruction (congestion)
      • Facial pain, pressure, or fullness
      • Decreased sense of smell
    • AND inflammation documented on one of the following:
      • Purulent mucus or edema in middle meatus or ethmoid region
      • Polyps in nasal cavity or middle meatus
      • Radiographic imaging with inflammation in the paranasal sinuses
Localizing the lesion in homonymous hemianopsia
  • Optic tracts
    • Lesions here can also produce a relative afferent pupillary defect called Wernicke’s pupil
      • Test: Shine light on intact hemifield and have normal pupillary constriction. Shine light on blind hemifield and pupillary constriction will be absent or diminished
      • Can be difficult to test due to light scattering across the iris
  • Lateral geniculate nucleus
  • Optic Radiations
    • Internal Capsule
      • Lesion often also affects corticospinal tract and corticobulbar tract —> Contralateral hemiparesis and and hemianesthesia
    • Temporal lobe
      • More often presents as “pie-in-the-sky” visual loss in addition to aphasia, memory deficits, auditory and visual hallucinations
    • Parietal lobe
      • More often has incomplete homonymous hemianopsia and contralateral hemineglect
  • Occipital lobe 
    • Most common cause
    • Most commonly due to vascular lesions 
    • Often have macular sparing due to bilateral representation of the macula in the occipital lobe
  • MRI is the test of choice to evaluate the optic nerve
  • Patients with complete homonymous hemianopia should not drive
  • Patients with neglect from a parietal lobe lesion can have visual field neglect instead of true visual loss but will also have sensory neglect.  Best way to rule out neglect as at the cause of the visual field findings is to do extinction testing on sensory exam.
Link to Evernote: https://www.evernote.com/l/AMr89m1D3H9En5_RleQ-Gtaw77ISuZuSU54
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