CASE 20-2016: A 50-Year-Old Man with Cloudy Vision,

Hearing Loss and Unsteadiness

III. Patients Profile
A. Demographic
Name: M. M. M.
Address: Boston, Massachusetts
Age: 50 year old
Gender: Male
Civil Status: Married
Occupation:
Nationality:
Religion:
Admitting diagnosis:
Date of Admission:
Time of Admission:
B. Chief Complaint
Cloudy vision
C. History of the Present Illness
Cloudy vision that gradually developed in both eyes last 3
days.
o with resports of fatigue and worsening of rash, joint
pain and stiffness associated with his psoriatic
arthritis.
o Topical opthalmic prednisolone was prescribed for

presumed psoriatic arthritis associated iritis.

After 5 days, cloudy vision persisted and that decreased
hearing and difficulty balancing had developed.
o A diffuse rash characterized by erythematous
plaques and overlying white scales was present in his
face, abdomen, back, arms, legs, palms and soles.
o Topical opthalmic Prednisolone was continued, and

opthalmic cyclopentolate was prescribed.

11 days after initial evaluation, hearing loss and
unsteadiness worsened and patient was seen by an
otolaryngologist.

o Patient returned to the eye and ear infirmary

because of worsened visual cloudness and a new
floater in the right eye.
D. History of the Past Illness
Laser surgery for retinal tear in left eye 16 years ago.
Pneumocystis jirovecii (10 months ago) and was diagnosed of
HIV infection
o Started antiretroviral medications 2 months before this

consultation
6 weeks before consultation, patient was admitted to another
hospital.
o Adrenal insufficiency, disseminated infection with
mycobacterium avium-intracellulare, and the immune
reconstitution inflammatory syndrome were suspected.
o Anti retrovirals were stopped and azithromycin,
rifambutin, ethambutol, hydrocortisone and
fludrocortisone were given as was trimetroprim-

selfamethoxazole 3 times a week.

2 weeks before consultation, anti retrovirals were again
initiated.

E.

Social History
Lives with husband
Non smoker and no history of use of illicit drugs
Social drinker

F. Allergies
No known allergies noted.
G. ASSESSMENT
Date: Initial evaluation
Vital Signs:
Pulse Rate: 91 bpm
Respiratory Rate: 20 bpm
Blood Pressure: 121/77 mm Hg
Oxygen Saturation: 100%

1. Physical Assessment (Initial evaluation)

1. General

-alert and oriented to person, place

2. Eyes

and time.
-pupils equal and reactive to light;
no relative afferent papillary defect.
-Visual fields full in response to

3. Skin

confrontation.
A diffuse rash characterized by
erythematous plaques and overlying
white scale was present and
involved face, abdomen, back,
arms, legs, palms and soles.