CASE 4 PBL 6 CNS by Afif Al-Ikhlas

Trigger 1

afifikhlas — 2023-11-30 02:53:20 UTC

Trigger 2

afifikhlas — 2023-11-30 02:55:42 UTC

Trigger 3

afifikhlas — 2023-11-30 02:56:08 UTC

Trigger 4

afifikhlas — 2023-11-30 02:56:45 UTC

afifikhlas — 2023-11-30 02:57:10 UTC

afifikhlas — 2023-11-30 02:57:34 UTC

TRIGGER 1

2023-11-30 03:04:45 UTC

Caucasian: MAT SALLEH

monocular vision loss: Loss sight in one eye

TRIGGER 1

2023-11-30 03:05:00 UTC

A 27-year-old Caucasian female

painful monocular vision loss developed

last two days.

TRIGGER 1

2023-11-30 03:05:10 UTC

-A 27-year-old Caucasian female: 27 young adult, good immune system, caucasian get cystic fibrosis,cancer, female: hormone change in menstrual cycle

-painful monocular vision loss developed : had trauma cause loss vision, common causes: (vasospasm)

-last two days: symptoms short period. immediate intervention

DIFF. DIAGNOSIS:

-optic neuritis

-hyphema

-close/open glaucoma

-cornea (corneal abrasion)

-retinal detachment

-conjunctivitis (infection-HSV)

-traumatic eye injury

-ischemic optic neurophathy

-OCULAR MIGRAINE

FURTHER QUESTIONING:

-HOPI: SOCRATES (pain-when it occur can differentiate with others)

-PMH: past ocular history, past ocular surgery, medical condition, allergy, other medication, hypertension

-family history: any eye disorder that lead to monocular vision loss

-social history: smoking, alcohol

-environmental factor: exposed to any pollution (irritate eye)

trigger 2

2023-11-30 03:28:45 UTC

fleeting episode - temporary occurrence or moments
paraesthesia - sensation of numbness or tingling
OTC - drugs can buy without prescription

trigger 2

2023-11-30 03:32:52 UTC

she developed discomfort in the left eye which became worse with
eye movements
progressive blurring of left eye vision
coloured objects appeared pale or washed out compared with
their appearance through her right eye
no right eye
symptoms.
no previous ocular history
fleeting episodes of limb paraesthesia several times in the past
year lasting minutes
Past history of asthma but took no regular medications
not on prescription or OTC medication
No history of head/eye trauma or surgical procedures
cousin with multiple sclerosis (MS) and she was very
concerned about her own risk of developing the condition
no history of alcohol abuse or illicit drug use.

trigger 2

2023-11-30 03:45:49 UTC

she developed discomfort in the left eye which became worse with eye movements - dry eye (due to aircond), any debris exposure, use of any contact lens
progressive blurring of left eye vision - refractive error, refraction, retinal issue, glaucoma, migraine and trauma
coloured objects appeared pale or washed out compared with
their appearance through her right eye - problem in colour perception (maybe damage to optic nerve or photoreceptor)
no right eye
symptoms - right eye normal, patient present with unilateral occular symptom, lesion anterior to optic chiasm (if posterior both eye affected)
no previous ocular history - patient not having any significant eye related issue
fleeting episodes of limb paraesthesia several times in the past
year lasting minutes - neurological condition (disruption of nerve signal then sensation occur), develop to all parts of body, not localised
Past history of asthma but took no regular medications - asthma just mild or intermittent, just used inhaler
not on prescription or OTC medication - anti-TB cause optic neuritis or uses of steroid (prednisolone) can cause glaucoma
No history of head/eye trauma or surgical procedures - exclude traumatic and surgical cause, more to inflammation and neurological condition
cousin with multiple sclerosis (MS) and she was very
concerned about her own risk of developing the condition - high risk get MS because she is Caucasion, MS cause vision loss, MS involve CNS (immune system attack myelin sheath)
no history of alcohol abuse or illicit drug use. - exclude alcohol and drug causing pain in patient

DIFF. DIAGNOSIS:

-optic neuritis

~~-hyphema~~

-close/open glaucoma

-cornea (corneal abrasion)

-retinal detachment

-conjunctivitis (infection-HSV)

~~-traumatic eye injury~~

-ischemic optic neurophathy

-OCULAR MIGRAINE

FURTHER QUESTIONING :

vital sign : temperature (high-infection), BP, RR, HR
physical examination - observe patient, do visual examination (fundoscopy), neurological examination (cranial nerve assessment)
visual acuity (first) - use to measure ability of eye to distinguish shape and detailed of objects at given distance (normal 6/6)
external examination of eye - eyelid, eyes, check for swelling, discharge or redness (both right and left)
occular motility and engagement - motility (eye to move and align) and engagement (assess function of extra occular muscle)
pupillary examination - check for pupil size, simmetry, shape and colour, pupillary reflex (light and accomodation reflex)
fundoscopy - check for edema, infarction and inflammation (macula, optic disc)
visual field testing - check for any extent of visual field loss
color vision testing - check ability to distinguish colour
intraocular pressure test - patient cornea flattened to measure IOP to rule out glaucoma (high IOP)
cranial nerve examination - check any neurological disorder
systemic examination - to rule out other system disorder that can lead to this kind of presentation

TRIGGER 3

2023-11-30 04:09:28 UTC

ophtalmoscopy - examination of eye back include retina, optic disc, choroid and blood vessel

TRIGGER 3

2023-11-30 04:12:41 UTC

eyes and orbit appeared normal.
Visual acuity was 20/20 on
the right eye and 20/40 on the left
left eye red desaturation and abnormal colour vision on Ishihara
plate testing.
pupils were equal in size
left relative afferent pupillary
defect was noted
There
were no haemorrhages or other abnormal retinal findings
found looking to the extremes of gaze painful in the left
eye.
Remainder of the cranial nerve examination was normal
Strength,
coordination, and sensation were normal, as was a gait examination
Systemic examination was unremarkable.

TRIGGER 3

2023-11-30 04:24:44 UTC

eyes and orbit appeared normal - no observable abnormalities
Visual acuity was 20/20 on the right eye and 20/40 on the left - normal visual acuity
Visual fields were full to confrontation. - indicate normal peripheral lesion, no visual defect detected
left eye red desaturation - cant differentiate color, effect optic nerve, mostly men
abnormal colour vision on Ishihara
plate testing. - indicate reduce colour receptor in left eye due damage of optic nerve
left relative afferent pupillary defect was noted - RAPD, abnormal finding in pupillary response to lighting, normal in optic neuritis
the cornea, anterior chamber, lens and vitreous humour appeared normal in both eyes, as did both optic discs - no abnormal found in structure, problem at posterior part of eye but before optic chiasm such as problem with optic neuritis
There were no haemorrhages or other abnormal retinal findings - not associated with bleeding in retinal blood vessel, exclude retinal detachment
found looking to the extremes of gaze painful in the left
eye. - sharp pain during eye movement
Remainder of the cranial nerve examination was normal
Strength, coordination, and sensation were normal, as was a gait examination
Systemic examination was unremarkable.

DIFFERENTIAL DIAGNOSIS

optic neuritis

~~-hyphema~~

-~~close/open glaucoma~~

-~~cornea (corneal abrasion)~~

~~-retinal detachment~~

-~~conjunctivitis (infection-HSV)~~

~~-traumatic eye injury~~

-ischemic optic neurophathy

-~~OCULAR MIGRAINE~~

FURTHER INVESTIGATION

MRI
CSF examination
FBC
ESR
CRP

TRIGGER 4

2023-11-30 04:40:52 UTC

1.gadolinium contrast-enhanced MRI- enhance the visibility of other structure or abnormalities

2.oligoclonal bands-protein (immunoglobulins) indicate MS-immunological response

3.clinically isolated syndrome (CIS).- attack of CNS, inflammatory. demyelinating symptoms of MS

Trigger 4

2023-11-30 04:43:07 UTC

1.Complete blood count, basic biochemistry, B12, folate and inflammatory
markers were all normal.

Imaging studies
2.A gadolinium contrast-enhanced MRI of the brain and orbits and spinal cord was
obtained.

3.The results showed demyelination of optic nerve with normal spinal
cord.

4.No cerebral lesions were detected.

5.A subsequent cerebrospinal fluid (CSF) examination was normal, with no
leukocytes or oligoclonal bands detected.

6.The patient was diagnosed with left-sided optic neuritis and a clinically isolated
syndrome (CIS).

7.Treatment with intravenous methylprednisolone is started and followed by oral
prednisone for a week.

8.The patients vision recovered within the first week of the
treatment.

9.A repeated MRI scan of the brain during the follow up examination in 1 month
was reassuringly normal.

Trigger 4

2023-11-30 04:51:52 UTC

1.Complete blood count, basic biochemistry, B12, folate and inflammatory
markers were all normal.

-to know contributing fx

-Localised

-not due to nutritional deficiency

-detect autoimmune

Imaging studies

2.A gadolinium contrast-enhanced MRI of the brain and orbits and spinal cord was
obtained. The results showed demyelination of optic nerve with normal spinal
cord.

-inflammation at the optic Nerve(high risk MS) but normal SC(no demyelination-low risk of MS)

3.A subsequent cerebrospinal fluid (CSF) examination was normal, with no
leukocytes or oligoclonal bands detected.

-not involving CNS

-no MS

4.The patient was diagnosed with left-sided optic neuritis and a clinically isolated
syndrome (CIS).

-risk to get MS

7.Treatment with intravenous methylprednisolone is started and followed by oral
prednisone for a week.

-corticosteroid- [potent antinflammatory & immunosuppressive effect ( to Tx )

8.The patients vision recovered within the first week of the
treatment.

-glucocorticoid (prenisolone) 1st line

-antinflammatory & immunosuppressive effect

9.A repeated MRI scan of the brain during the follow up examination in 1 month
was reassuringly normal.