Medical student Challenge #3 of 4

Are you a medical student or a resident?  Or do you like challenges? Do you want to try to figure out the diagnosis? Below is a challenging patient case.  See if you can solve the case.  Send in your diagnosis to


Imagine that you are a third year medical student doing a family practice rotation. You have a patient who is here for an outpatient clinic appointment.


A 45-year-old woman complains of 3 episodes of vision loss of the right eye.

The first time it occurred was about 2 months ago. She had entered her car after doing errands and experienced complete vision loss of the right eye. She blinked a few times, her vision loss resolved completely after a few seconds and then she started driving home and did not experience any other problems that day. The second time she had vision loss was last week. She had been watching television when she lost vision in the right eye. She turned the television on and off, went to wash her face, and noticed that her vision returned to normal after 5 minutes. Most recently it occurred yesterday. While she was at work, she suddenly felt as if a shade was coming down to cover her right eye. The episode lasted for what seemed like a few minutes. 

She looked up her symptoms on the Internet and decided to get it checked out.


She has been a smoker since age 19 and doesn't want to quit because she says it prevents her from snacking and she wants to keep her weight down.

She has been taking oral contraceptives off and on since she was 18. She has 3 children and all 3 pregnancies and deliveries were without any complications. She drinks 2-3 beers a few times per week, usually on weekends. She had a seizure about 10 years ago and was on phenobarbital for about a year without recurrence.

She has not had any seizures since then. She gets migraine headaches about 2-3 times per year and has been treated with injections in the emergency room a few times. She was given a prescription for Fioricet after one of the emergency treatments and she uses it a few times a year, generally with an effective response and no side effects. 

Her family history is significant for asthma and heart disease.


Physical exam 

Thin well nourished appearing woman with no obvious signs of distress.

Skin appears normal.

Her throat is normal.

Cardiac examination reveals regular rate and rhythm.

Chest exam is significant for some wheezing.

Abdominal exam is normal, with no pain, tenderness or masses.

Her pulses are palpable and normal in bilateral upper and lower extremities. Her carotid arteries are normal with no bruits.

She has a slightly enlarged thyroid.


Neurological examination

She is alert and oriented x3.

Her speech is normal.

Her extraocular movements are intact with no nystagmus.

Her pupils are equal, round and reactive to light.

She does not have ptosis or facial asymmetry.

Her sensation and movements are normal on both sides of her face.

She has normal strength in the bilateral upper extremities and bilateral lower extremities.

Her reflexes are normal in the upper and lower extremities.

Her sensation is normal to touch, pinprick, vibration and position sense.

She does not demonstrate ataxia or dysmetria in bilateral upper and lower extremities.

Her gait is normal and she can perform a Romberg test and heel to toe without any difficulty.


What do you think is wrong with this patient? Do you think you should order any diagnostic tests or initiate treatment and, if so, which medical tests, which diagnostic imaging tests and which treatments? 

*If you like The Doctor Game, see the June and July questions*

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