6. The Sight

'Hey, Lisa! Can I ask you a quick question?’ Kate asked me while we took a break in the cafeteria. It was a holiday of some sort that day. We didn’t have all the staff in, but I remember I was there, Peter and my intern Kate. We were covering many patients so it was a packed day.

‘Of course! What’s up?’

‘I just saw a 34-year-old woman who was admitted last night after a head trauma that followed a syncope. Since then she has been going well but has a persistent headache. She said she has had other episodes in the last few months but never came to the hospital before. She was previously healthy. The neurosurgery team was taking a conservative approach but due to her persistent headache, they are considering a CT scan. However, her last menstrual period was 9 weeks ago, so they ordered a Beta-HCG and it was negative, so they called our consult. I can clear her for the exam, right? ’

‘Right, but… why is she passing out?’

She seemed surprised by the question.

‘Hum, I don’t know.’

‘She really has no other symptoms?’

‘Well, she has had a recurrent headache for a few months that resolves with analgesics.’

‘Is it getting worse? The headache.’

‘Not sure.’ She was a little insecure.

‘Nausea, vomiting, galactorrhea, weight changes?’

She scratched her head anxiously. ‘Honestly, I don’t know. The consult was about the risk of pregnancy, so I didn’t think to ask.’

‘Not a problem, we can ask her now. What about her sight?’

‘She has no complaints.’ Kate said.

‘But did you test it?’

‘No. Should I?’ She giggled and so did I.

‘This will be fun.’ Peter said and winked at me. I guess we were both thinking the same thing.

‘Let’s go see her.’ I said to Kate but Peter followed us.

Kate introduced us to Mrs. Porter. She was a good-looking woman that looked eager to get discharged.

‘How are you feeling, Mrs. Porter?’ I asked her.

‘I’m okay. I just want to go home, I really need to get back to work.’ She smiled.

‘I understand. From what Dr. Anderson told me you are still feeling a headache after the fall, right?’

‘Yes, I am, but I always have headaches, it is no big deal.’

‘What do you mean by always?’

‘Almost every day, for a couple of months. Work has been stressful.’ I looked at Peter and he winked at me. It seemed like maybe we were right.

‘What about nausea or vomiting?’

‘Not really, although I have passed out sometimes, like yesterday.’

‘I see. What about your period being late? Is this the first time it happened?’

‘Well, without being pregnant, yes.’ She laughed. ‘But in the last couple of months, it has been a little more irregular than usual.’

‘And are you having any nipple discharge?’

‘No, I’m not.’ She seemed confused with the question.

‘Okay, I am almost done. What about your vision, is it good?’ She nodded affirmatively. ‘Would you mind if we did a rapid test with you?’

We were all shocked when we realized that she basically had no peripheral vision at all. My hand was on my shoulder when she was able to see it. Even the patient was a little surprised by it. We told her we would discuss her case and would be back soon to talk more about it.

When we left her room I turned to Kate and she had already figured it out.

‘Prolactinoma.’ She said.

‘Yep.’ I smiled. ‘It’s either that or a non-functioning pituitary adenoma. Not every patient with prolactinoma has galactorrhea. They can present only with headaches, amenorrhea, and loss of peripheral vision. In her case, she is even having syncopes, which may be related to a space-occupying lesion.’

‘Damn it.’ Kate thought out loud.

‘Don’t beat yourself up. Now you are never going to miss this again.’ I smiled at her. 

‘That’s for sure, from now on every patient of mine with amenorrhea will get at least a visual field test.’ She laughed.

‘Exactly.’ I laughed back. ‘But remember, we should see consult patients as our own, otherwise we can miss important diagnoses without even noticing it. Anyway, now we should switch her CT scan to an MRI, don’t you think?’

‘I’m on it.’ She went to discuss it with the neurosurgery team.

‘What?’ I asked Peter who was staring at me and laughing after she left.

‘Don’t beat yourself up? Really? You do that all the time.’ He teased me.

‘Shut up, Peter. Just because I do it, it doesn’t mean she should.’

‘You should follow your own advice more often, Dr. Diaz.’

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MC: most common; Tt: treatment; ag: agonists.

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