Diagnostic Cases

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Diagnostic Cases
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CASE 1

• Patient aged 75 ,female,presents with a history
  of 3 episodes of going blind

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First Impression

• What are the likely causes?

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• Embolism?
• Migraine?
• Cerebral vascular insufficiency?
• Temporal arteritis?

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Further History Required

• List 10 further questions you would like to ask.

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Suggested Questions

• What do you mean by blind.
• How long did it last?
• 1 or both eyes?
• A general blur or localised?
• Horizontal or vertical?
• Can you draw the disturbance?
• Did it pulse?
• Did it completely recover?
• OK after?
• Anything else happening to you eg feeling faint ?

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Answers

• Lasted 30 seconds on 3 separate occasions twice
  recently and one, 1 month ago.
• Cant remember if it was same eye think it was
  the left.
• Came like a blind from below and faded back the
  same way.
• Vision OK after. No headache.
• Been getting a lot of headaches lately behind the
  left eye and into my jaw.

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Further History

• At least 4 more questions

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Suggested Questions

• Vision OK?
• Migraine in past?
• Pain on mastication?
• Scalp tenderness with brushing hair?

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Answers

• Vision a little blurred in left eye.
• Overdue for glasses.They havent sent for me yet.
• No difficulty with eating.
• My head is always sore.
• I dont get migraine headaches.My mother had
  those and she used to vomit for days.

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General History

• What would you like to know about this womans
  general medical history.

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Answers

• Arterial history/arteriopath?
• BP history.
• Cardiac history.
• Medication.

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Examination

• List the eye examination steps.
• List the general examination steps.

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General Exam.

• BP.
• Carotid pulses.
• Scalp tenderness.
• Cardiac screen.
• Peripheral pulses.

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Eye Examination

• Va .With glasses and with PH.
• Pupils.
• Ocular movements.
• Confrontation field.
• Fundus exam. with dilating drops.

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Findings --General

• BP 180/95 (lying), 92Kgs.
• Weak dorsipedal pulses.
• Carotids OK.
• Scalp OK.
• On Atacand 16 mgms / day
• On occasional aspirin (1/2)
• Previously diagnosed with diabetes but does not
  believe the previous doctor.

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Findings Ocular

• Vr 6/9 Vl6/6 with glasses.No imp. with PH.
• Pupils/Ocular motility NAD.
• Fundus see slide.

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Provisional diagnosis?

• List 4 provisionals.

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Provisionals

• Migraine.
• Carotid embolisation.
• Temporal arteritis.
• Vertebro -basilar insufficiency.
• Systemic hypotension.

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Lab. Tests/ Imaging

• List

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tests

• FBC/CRP/ESR
• Fasting blood glucose.
• Lipids
• Electrolytes
• Carotid doppler.

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Results

• ESR 35/ CRP 3.
• Carotid doppler shows 65 0cclusion Left side
  25 Right side.
• Glucose 10.5
• Lipids Chol.7.7

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What to do next?

• List

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Refer Ophthalmologist Aspirin/ Clopidogrel Rx
BP/Diabetes/lipids. Weight reduction. Refer
vascular surgeon