Sorry I'm in the basement hey how are you I'm not doing not doing anything I'm anything I'm doing not anything oh you this is tony it's like tony so tony has unfortunately he has lost vision before in his eye and they thought it was a stroke but I think it's been in inconclusive so today around 9 9 this morning he's finished his breakfast he's been sitting down and he's kind of his vision's gone again so he's he's blind in his right eye normally he's blind in his left eye and he's also had feeling like he's gonna faint feeling he's feeling very nauseous has some episodes of vomiting right he's then also had he said he took his own blood pressure it was very high for him was about 1 50 which is apparently high it's been 120 with us but he also said at the time his blood pressure was high he's also then had an aching and weakness in his right arm so there's no classic kind of pronation drift but there is generalized weakness in the right arm seems to be on it on the right hand side seems to come and go sometimes he's able to use it sometimes he's not sometimes it's he hasn't yeah so I was I don't I don't know what's going on so from from what he's telling me I was like I'm just gonna bring your notes and see because it's something funky in ear 1 of mine oh yeah you're alright yes tony so you're you're you're normally blind blinding your right eye my right eye and now you can't see anything out of your left eye no I can see now okay it's not properly like I normally see what way is it different is it because it's not I'll just call the side here I'm a look and you can use it short yeah I got a surgical could you do any more describing in a mirror is there a part of your vision missing is there anything projected on front of your vision it's as if my eyes are not open properly to see you know to see you like it's completely black no no no I I can see you I mean when it started at 09:00 in the morning what were you doing I was having my breakfast at the time and I took all my tablets after that and now I felt have you had any problems thought he was sweating and I thought what's wrong with me and he took the tablets and he felt sweaty and he stimulated his vision my arm was aching was terrible it was aching yeah just right in the crease of my arm was aching and I then thought I'd take my blood pressure I took my blood pressure and it was at a 100 what did I say a 100 it was in the 1 1 50 okay it was hot really high for me yeah mhmm and then I rang my daughter-in-law from blue and she came over yeah because before she got to me I was sick I was like you got kids oh okay and I was just sat there in a chair at home mhmm and I couldn't stand up I felt I couldn't stand up okay and I haven't been able to stand up stand up since alright fine yeah he hasn't sat he was answering seems oriented then was kind of some questions was kind of giving an incorrect answer to the question I was asking yeah okay yeah and I couldn't tell my daughter would know what to do at home even I couldn't as if I couldn't remember yeah how where things were and how to do things very strange isn't it fine just I just walked me normally that's okay just do a structured assessment which is a set of few questions and ask you to do a few things is that alright what month is it that'd be alright lovely and how old are you I'm 77 can you blink your eyes for me yeah can you squeeze my hand and squeeze it with the other side that's fine could do better with that 1 better with that 1 yeah I see you definitely should use this that's okay can I see your eyes open you follow my finger with your with your eyes keep following my finger well it's blowing me now I thought I can't see it when you pull it right so over your nose can't see it but you can see it now I could see it through my left eye here now okay so a little bit it's fine it's alright just to test the fields of your vision I'll cover up this eye can you see my finger here I'm looking at my face not very not very well well you're you're lifting it up right yeah can you look at my face and see my finger in the corner of your vision slightly yes think and here I can see it down my finger heel right can't see it in your finger I can see it there okay but you can't really see it here I can see you moving it yeah you can see me moving it and on this side again up here not really well right well yeah I can see you move I can see it there and here yeah I can see you can see it when you look at it when you look at my face can you see it in the corner of your vision no I can see your face okay and is there any parts of my face like it normally is that's what's worrying me okay it's not my eyesight is not as good as what it normally you know I could normally see by it seems my left eye is not as good as what it normally is can you give me a big smile big smile 6 okay can you blow out your cheeks can you lift up your eyebrows really high can you scrunch up your eyes really tightly can you move your head side to side okay can you give me any more of a smile than you had before droop on 1 side of your face but it's just none of your face really mean really no okay not as my normal self that's what's worrying when you feel me touching your ear and your cheeks yeah feel the same on both sides exactly feel the same yeah how about here on your hands yeah and how about on your feet sorry yes feel the same on both sides can you lift your right arm up in the air for me my right arm lift it up like that keep it up like that keep it up that's okay keep it up if you can +1 (234) 567-8910 lovely can put that down how about this 1 will you lift your left arm up for some lovely I'll keep it keep it up for 10 for me +1 0987654321 should we try this right arm again that's good let's see it lift up are you going to look at it if I help you lift it up keep it there +1 23456789105 thank you that's lovely how about your legs I can hear this crept in slightly can you lift 1 of your legs up for us let's see your left leg first lovely +1 2345 that's fine you can lift your right leg up always have trouble yeah is it painful yeah it is a bit but always I always have to lift shrinks lift it 1 moment fine and if I help you lift it can you keep it there today I can't know it's it's heavy heavy today it's but I normally have to help it when I get in and out of bed and things mhmm or getting in the car can you show me some clapping like this turning your hand over like this put your eyes closed so you can't see turning you to show me another 1 can you try some clapping where you clap turn your hand over and put it down backwards yeah like that and up over and clap again so you put your finger to your nose yeah and touch my finger you probably can't see my finger because you've your eyes closed that's okay back to your nose again to my finger you touch your nose touch nose touch my finger I have trouble because that's why it's not good does it it's very good you're very good with it and with the right hand can you try a bit of past points on it sir past points thank you alright then what else do I need to do when I you know my when I'm normal I struggle to how good are you with my can you see my phone can you tell me what this is it's a bucket there mhmm can you tell me what that is a mouse fine you read these words for me it's down the bottom big ones just are start from the top and read mama mhmm tip top 50 50 thanks I'll call barry baseball player does your voice sound normal to you it sounds normal to me well I do sometimes wonder about that when I'm talking mhmm any difficulty finding words finding words yeah like finding the right word to say I think I'm a bit forgetful mhmm trying to remember things when I touch you just tell me which side of your body I'm touching you on my left hand good that's fine we'll just go and scan your head and see what's happening is that alright yeah cool thanks man did you request it yes you're a legend you know 5 6 something like that please leave and thrombectomy and you have a scan here this is anthony domaine 320761 77 year old gentleman plate is left visual changes and symptoms so scene by on the k3 that's on the january 8 in tia clinic after referral with 2 episodes of blurring of his vision and flashing lights in his left eye history of aortic root replacement in 2022 previous endocarditis and a previous right central retinal artery collision which resulted in blindness in his right eye convincing but the history was not entirely convincing of retinal artery occlusion referred to the rheumatologist for which had and underwent a temporary ultrasound which demonstrates thickening but no other signs of inflammation and normal crp degree of uncertainty with the diagnosis from the stroke team no evidence of significant stenosis in left internal carotid on carotid duplex scan in tia clinic good evidence of a cardioembolic source such as an lp thrombus in order to recommend altering current treatments the venous blood gas ph 7.48 sodium a 129 lactate 2.1 nm whole body pet fdg scan 02/22/2026 reported today but undertaken 2 days ago moderate increased uptake in the root of the ascending aorta in the region of the aortic root collection could be related to ongoing low grade inflammation rather than a low rather than a large vessel vasculitis moderate increased uptake in the wall of the root of the ascending aorta in the reach of the collection similar to background liver intermediate grade 2 uptake elsewhere uptake within the wall of the thoracic abdominal aorta is low grade asymmetrical increased uptake in the region of the fossa of rosenmuller which is in the ent and it's in the nose blood test from the eighteenth february demonstrated a crp of 2 with normal lfts and full blood count histology from the right temporal artery biopsy demonstrated marked internal thickening fragmentation of elastic fibers and a few lymphocytes present in the adventitia numerous calcifications in the thickness of the wall aspect described may suggest temporal arteritis but apparently inconclusive for that ultrasound doppler of both temporal arteries the right temporal artery was tortuous and with mild intimal thickening measuring 1.5 millimeters patent frontal vessel compressible with mild intimal thickening measuring 0.4 millimeters normal waveform velocities no halo or stenosis on the left there was mild and small thickening measuring 0.7 millimeters parietal and frontal measuring 0.4 normal waveform and velocities patient axillaries so on examination globally slowed minimal effort with facial movements nihss 1 2 mhmm yeah I've just I've just got it to to grade and there's like to right heaviness however squeezing power is present and right leg has persistent but long standing difficulty in lifting off the bed and he's been unable to mobilize presenting complaint is visual disturbance are they now in the wards okay so someone is seeing 17 now now medications list atorvastatin 40 mg once a day finasteride once per day pregabalin 50 mg twice per day frizanide 20 mg in the morning warfarin right as required as per inr bisoprolol 45 mg once a day aspirin 75 mg once a lanzoxazole 30 mg once a day latanoprost eye drops okay levothyroxine 125 micrograms once per day alright then okay thanks mizzy bye bye bye well yeah we've got it's it's accumulating now sorry tia 26 '20 12/16/2025 nondiabetic hypoglycemia ida hydrocele aortic root replacement january 2022 yeah yeah alright then thank you and stay on april 4 now thank you sorry that's what I know isn't it they're doing well it's still no problem just wanna start the left we run wow yep so past history of right central retinal artery occlusion with no perception of light in the right eye and 6 7 9 vision in the left eye back in 2023 right afferent pupillary defect evidence of previous embolic disease in the right eye retinal vasculature so treated for infected aortic root abscess so back in 20 22 74 so at that time in 2022 june was he was repatriated from derekud after surgery avi and aortic root bypass for infection and then reoperated for a re bleed already on meropenem and tyke which were continued and added a statin gint whilst inflammatory blocks continue to rise we stopped blood cultures stopped antibiotics and several blood cultures which were negative and no infection so 2 previous aortic valve replacements and root replacements 2017 and 2022 position he doesn't need to very fine I know yeah better it's a him to go on vacation or something have symptoms yeah or is it the know the way they're in our office yeah they look sad they'll do and they as 0.5 yeah it was yeah it was horrible and she said gary taking the same amount of drug that you're taking and how many days that was 10 mhmm so I'm 10 for 5 and 9 10 for that's fine got a little bit is that like the weekend you take lines during the week you take 10 yes more or less sorry if you have a therapeutic iron ore the chance of doing a block seems incredibly unlikely and your rheumatologist after having looked at everything suggested that you could turn it straight in hospital with more visual changes to treat with the 4 times a lot absolutely yes which would be some strong steroids knew you were asking exactly and or membranous really know I said they hadn't I haven't read them give me any steroids at that? No we don't like to give steroids because they spoil the biopsy results right because they can't come down any inflammation however given your hearing vision changes and you already had a biopsy I think it's safe to give you some steroids to see whether that makes it better and obviously you've got only your left eye because your right eye's pretty frowed so it's very important obviously to preserve the vision in that eye as much as we care yeah yeah and so I suggest we give you lots of steroids we check your inr to make sure that's in room and if it's not then we then we can change tabs and try and look at the prostate vessels local venous blood vessels for now I can look at the prostate we didn't image your we scanned you down to about here and then your aortic root's about there so we just missed it in that scan but we didn't know that aortic root was the scan well we didn't know about it then we I I only saw about it after yeah while we while you were in the scanner I was reading about it yeah it was a big problem I've been getting up to it that was 2017 when I was originally a sore mhmm I know I've got a mechanical yeah about that time yeah a couple of people oh no but that's the thing he was knew you wouldn't it yeah a really good so yeah it's a 1 and done kind of thing yeah it's but you had infection 1 time and bleeding another time I forgot I went into my throat oh no so I was in recovery 1 night oh yeah and then I had a massive bleed or something and they didn't know yeah blood clot in my eye you know and that was before you were on the warfarin yeah is that right yeah yeah yeah and that's why you're on the warfarin I guess because you grew up a clot in your metallic valve from your infected root maybe you had a tissue valve then the loss of a sodium chloride was oh well I've had things that came out of there but maybe you had I'm sorry really happy maybe if you were on if your bowel was kicking or unhappy then it's kinda full of your throat collapse yeah that's fine comes up so it's good that you didn't have a clot while you were on warfarin and that's obviously good can I have a quick look at you is that okay no no no no no no no no has he hit it with anything no that's just been in the garden and sorts of things and you get a bit of mop or something yeah that's fine okay and can I have a look on the other side have you had any other others seen it in the garden so it's a bit of panic and panic attacks on and it's these messy things on and I'm gonna ask you for a minute yeah that's what I have to do with you 2 you know that's lovely so you're starting to look good I'm gonna oh we're worried he can't I would say you got over like your oranges mhmm oh no any sore shoulders or anything like that well I do suffer with shoulder attacks okay and I get sore shoulder blades sure shoulder blades you know spongy skin no scratches stiff shoulders in particularly in the morning not really and this stiffness that you've got in your right arm at the moment is that have you had that before no sorry this stiffness that you've got in your right arm at the moment might have done once but not so bad as what it was today and how's the movement here at the moment it's painful it's it doesn't feel exactly right but hurting in my I can move it now whereas I couldn't couldn't even lift it up at all like mhmm mhmm that was like a couple of hours ago now I suppose yeah it feels much better now it seems better now yeah can you try that lifting your arm up a little bit again and is it stiffness in your shoulder or is it weakness that stops you lifting it no I don't know no don't think it's stiffness in your shoulder can I move your shoulder up no is it stiff to my heel and if you put your arm up there and you hold it up 1 3 2 4 4 3 part would you lovely how about your legs can we see those again alright I can't they're well they've damaged the nerves in my leg when they've let you through my groin that's what they've said so you've always got weakness I've got nerve damage in that leg the nerve is coming out that's just another problem it just seems to be 1 thing after another there'll be 1 thing on it gonna help us feel like it's all good bad no you just need to be praying to all these things well you to add to first heart that I was never went to the doctor never been in the hospital fair enough once we get our closing yeah we have to be like that means the last month I've been down here all the time till I've been out of thing literally yeah we had a lot of appointments haven't we a lot can you tell me what month it is good good can you tell me how old you are can you please my finger just like me can you blink your eyes oh you can that's what happens no that is the video okay just ask me to find my fingers yeah what are you doing choosing I've got a meeting and I've got see now she's actually most shoes that's what mel's gonna do okay good that's fine but you know what I'm saying like the most people around me no I'm just gonna do the thing and mel if I cover your eye up can you that in the corner of your vision can you see it clearer than before yes fine and how about down here yes so it depends on what's happened with you and how much you're feeding and on this side it's it's pretty dark isn't it okay can see it can you count fingers on this side can you see my fingers 2 3 okay but you're at that kind of level on the side yeah I know you know when I'm looking I can't you put my hand there but and you're further out can you see your nose is there no I can't see can you give me a big a big smile I I'm happy I have what I'm supposed do fine how about you too no I'm just gonna do that I'm supposed to can you lift your eyebrows up really hard no has changed a bit it's sort of to me it sounds sort of tropey I don't know do you think that no well I mean yeah I have noticed it when you're talking to your own phones or something yeah it it doesn't sound like it used to yeah okay it's but in terms of the you feel like you're listening or slowing your work that doesn't sound like you are to me no I don't wanna say I'm slurring it up it's just my the character of voice yeah it's it's teenagers it's sort of like you if your voice is dry like you know I mean you're a bit sort of spooky when you're talking that sort of thing feel me touching you here here here on your cheeks and here on your feet I can feel this 1 more than this 1 but that's always been the case yeah it's better I was gonna say yeah because my nerve damage can feel it I mean it's always cold in my leg it's especially up from my knee up to the thigh that's always cold yeah and if I sit down I'm very often a lot of time I know I'm weak I'm weak you know in the evenings and things like that mhmm and during the daytime winter time it's sort of cold can we do the nose to finger test is that alright can you put the other eye on your to your nose and into my fingers I think she's got everything oh she goes to your nose again with my finger again if you took my finger my dissection there is not you're not sure whether you're touching well with only 1 eye it's quite difficult to escape when I'm doing things so I can't see what I'm doing or need both eyes and I've got to pick 1 before pick somebody does but I'm nowhere near it like if you need to please like yeah alright but you're not past pointing like you were before before you clearly went past it yes you're not doing it now can I see with your left hand I'm gonna get done with your left hand this time sorry no don't worry that's better isn't it come on yeah got on a message she's coming to charity but you can sign to cat have I asked you to name some things last time much can you name any of these items for me family charity and you can sign to cat it we can you can use a table when you're done with that yeah you know it's worth anything yeah very good good all done so I I just put you a doctor when I take you an side and get you an they talk good knife because that's the of course whatever it is and I do struggle with that sort of stare at it mhmm and do you have do you still have visual changes on that left hand side you still do you still not look right I don't say it's a 100% no but it's better than what it would have been earlier so the the tests that I've done are very reassuring and the things that got better quite quickly I mean the stroke they didn't get better this quickly and then you your score where you came in with me was 6 and now it's 0 so I can't detect any residual deficit on those structured tests no but obviously the visual changes are something we should do something about I suggest we bring you into hospital and give you some strong intravenous steroids to dampen down inflammation that might be affecting the vision in the left upper knee and then get you seen by a rheumatologist rheumatologist in the morning yes so I'm gonna check down here probably staying in hospital for how to control the hemosteronis and then being seen by them as an inpatient or iv driving for them to decide whether they think this is a giant cell arteritis and inflammation in the blood vessels based upon all the tests we've done or whether this is something else mhmm but I think covering them with steroids is the right thing to do to make sure that so has he had anything sort of in him has he he hasn't had any treatment settled on his own he doesn't have any treatment no you thought it was likely unknown no that was nothing like it is I think very strange a lot of tests that you've been in you've had to scan your head so you've got a ct you've got a blot and contrast oxygen the vessels in your head and there's no large vessels occluded in your brain and you've had some blood tests that I haven't seen before and you need to have a tracing of your heart to tell if you have a tracy okay gonna a tracy of your heart okay I'm tracy I'm I'm sure if we go for an eye check up tomorrow okay farber after that you need an ophthalmologist yeah yeah like a 6 monthly thing mhmm because I'll put drops in the eye yeah so you've got a couple of a galvanos yeah I've a pulmonary vein sort of yeah means you've got a small cataract on that left and then you've a low well not I mean that's that's mainly the risk of blindness when your blood vessels are inflamed large vessels in the axial arteritis is a large vessel vasculitis so it affects large blood vessels so not the blood vessels in the kidneys the back after you're under the skin it affects larger vessels like the large vessel that supplies your eyes the temporal artery but it can also affect any artery and the larger artery in your body so it's possible your follow-up is the same as how I eat so it's possible do you have a and it seems to be what I imagine is when I look down at some time really yeah yeah yeah well if I go to my fridge and let if she walks in the fridge I'll pretend to have the fridge yeah and sometimes I think oh my head's up and when I look up and down mean it's not been time it's ever since I think I've more or everybody that you know nothing's been negative I'm in a bit really low that's right and I still get it a bit now but not so much not quite so much as what I was getting it was getting it every day every couple couple of hours was feeling this pain in my throat and the headache is very commonly associated with that inflammation in the blood vessels it sort of comes and goes I described it as being like a migraine I don't get migraines know not normally but it's sort like the zom zom zom know and I said it's either my forehead or my eye mhmm no it's fine you've been on to so many tests because you don't have an operation should I say nobody's seen seen taken that to me no so I think I've a lot hair on it before I walk oh you you did no what k dream form stay to lock this that's what she and you suggest going out there to sleep something that's good did they need to do anything no it's fine I've added on a proper blood test okay so I'll talk about that now thanks very much thank you thank you so on examination nihss on admission 6 and nihss now 0 45 minutes following admission heart sounds metallic aortic valve heard with soft systolic murmur muddest in the aortic region on expiration chest clear to auscultation abdomen's often on tendon no peripheral edema now no limb weakness on examination but and no hemianopia but persistent nonspecific visual changes and blurriness identified impression has been compliant with warfarin impression is of well I mean history of presenting complaint is so has been having investigations recently for giant cell arteritis and also under the tia clinic for possible haemorrhosis fugax recent tests including ultrasound of the temporal arteries temporal artery biopsy and most recently pet ct scan all inconclusive for diagnosis of giant cell arteritis although history is typical rheumatology letter recommends initiation of steroids if presents with further visual disturbances and today presents with onset at 09:00 this morning of left visual blurriness haziness aura and inability to see objects further away with possible superior left quadrantanopia on on initial examination in the right eye he has no vision due to previous retinal vein occlusion associated with this he's had some dull right elbow pain and right shoulder pain leading and associated mild drift of the right hand side but with reasonable power on the right hand side impression is of thromboembolic vent affecting the eye versus related to secondary to infected aortic root versus flare of giant cell arteritis leading to visual disturbance he's got no symptoms of polymyalgia rheumatica plan is blood tests including inr if inr therapeutic then for oh and for his warfarin he takes 10 5 times a day and 9 2 time 10 5 times a week and 9 mg 2 times a week number 2 12 lead ecg number 3 if blood tests demonstrate inr within therapeutic range then for initiation of methylprednisolone or high dose steroid check the guidelines if iron are subtherapeutic then consider thromboembolic disease and load on aspirin and discuss with ophthalmology admit to acute medical unit not stroke ward rheumatology review marnay tep full escalation and social history is independent he lives with his wife he work goes out in the garden on examination he's got a single right thumb splinter hemorrhage but none others on his hands and no other stigmata of endocarditis