Harry, a 62-year-old man, was brought to the emergency
department following a generalized convulsive seizure. Once he had regained
consciousness and his post-ictal
confusion had cleared, he was able to give the following history.
Beginning about 6 months before the seizure, he
had begun having bifrontal headaches that were dull in quality and generally
worse in the morning. Over the next few months, the headaches increased in intensity
and duration, and he began having brief episodes in which he saw flashing colored
lights off to the right hand side of his field of vision. These episodes were
always the same: they began suddenly, lasted approximately 1 to 2 minutes, and
then ended just as quickly. Like the headaches, the flashing lights had been
increasing in frequency up to the day of admission when a typical visual episode
was followed by a convulsion. Otherwise, he had no complaints, although he did
mention that he had had two auto accidents in the previous month, both times
hitting parked cars on the right hand side of the street.
On examination, he was alert, awake and oriented with normal speech. Both optic nerves were swollen. The visual acuity was normal and the pupils normally reactive. However, he could neither see to the right with either eye alone nor with both together. There was no other cranial nerve deficit; and the motor strength, tone, and coordination were normal. The deep tendon reflexes were also normal, and the plantar reflexes were flexor. Sensory function was intact. His stance and gait were narrow based, but he tended to brush against walls and doorways with his right shoulder. Romberg's test was negative.
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