Washington – Physician Assistant – History Of Diabetes And Hypertension With Chest Pain, Left-Sided Weakness, Headache, And Loss Of Vision

On 11/7/2011, a patient presented as a “medical emergency” and was seen by a physician assistant at a correctional facility.  The patient was a 62-year-old man whose medical record included a history of arthritis, diabetes, and hypertension for which he was treated with blood pressure medication.

The patient told the physician assistant he thought he had a stroke three days earlier and described symptoms of chest pain, left-sided tingling, left-sided weakness, headache, and loss of vision in the bottom visual field of his left eye.  The patient’s presenting blood pressure was 180/94 with a repeat at the end of the visit of 127/82.  The physician assistant noted normal pupil, funduscopic, heart and lung exams.  Cranial nerves II-XII were intact.  The patient’s strength was equal bilaterally.  An EKG was done and interpreted as having a normal sinus rhythm.  The physician assistant’s diagnosis was “No evidence of stroke.”  The patient was given a GI cocktail and released to his unit.

The physician assistant did not verify the patient’s complaint by conducting a visual field exam.  The physician assistant did not consider temporal arteritis as a possible cause of the patient’s vision loss.  Also, he did not at that time discuss his care of the patient with a supervising physician.  The physician assistant failed to recognize the emergent nature of the complaint of sudden vision loss by a patient.

The patient again presented to the physician assistant a week later on 11/14/2011.  He reported continued loss of vision in the bottom visual field of his left eye. The physician assistant completed a form recommending the patient be referred to an ophthalmologist.

The patient was seen two weeks later on 11/29/2011 by a local ophthalmologist who ordered a sed rate to help rule out temporal arteritis and placed the patient on clopidogrel.  The ophthalmologist diagnosed “[a]cute anterior ischemic optic neuropathy OS.”  He stated that at the visit the patient was “already showing signs of superior optic atrophy and inferior visual field loss from superior involvement approximately three weeks previous.”

The Commission stipulated the physician assistant reimburse costs to the Commission and write and submit a paper, with bibliography, on the evaluation of a patient with non-traumatic sudden vision loss.

State: Washington

Date: August 2017

Specialty: Physician Assistant, Family Medicine, Internal Medicine

Symptom: Vision Problems, Headache, Chest Pain, Weakness/Fatigue

Diagnosis: Ocular Disease

Medical Error: Diagnostic error

Significant Outcome: N/A

Case Rating: 5

Link to Original Case File: Download PDF

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