PATIENT’S IDENTIFICATION Name
: Ms Z
Age
: 57 years old
Gender
: Female
Rae
: Malay
Rel!g!on
: Islam
O"#a$!on Address
: %o"se&!'e : (lang
Reg!s$ra$!on Reg!s$ra$!on n"m)er *RN+: ,7---./ Da$e o' adm!ss!on
: -70.0-1,7
Da$e o' ler2!ng
: -30.0-1,7
C%IEF COMP4AINT %er son no$!ed $a$ se as a s6"!n$
%ISTOR8 OF PRESENTING I44NESS
Ms Z9 &!$ "nderly!ng r!g$ eye a$ara$ 'or , year9 d!a)e$es mell!$"s 'or 3 years9 y#er$ens!on and dysl!#!dem!a 'or 5 mon$s9 &as a##aren$ly &ell "n$!l 5 days ago &en !s son no$!ed $a$ se as a s6"!n$ %e real!ed !$ &en se o"ld no$ mo;e er r!g$ eye $o $e r!g$ s!de &en se &as $al2!ng $o !m I$ &as s"dden and asso!a$ed &!$ #a!n a$ $e r!g$ eye)ro& reg!on Te eye)ro& #a!n &as non
PAST MEDICA4 %ISTOR8 •
•
•
•
Ms Z as "nderly!ng a$ara$ on er r!g$ eye 'or , year Se !s om#l!an$ $o er eye e2"# !n Eye >ard o' %os#!$al and se !s #lanned 'or a a$ara$ s"rgery $!s A#r!l !n %TAR a'$er er r!g$ eye mo;emen$ !s orre$ed Pre;!o"sly9 se ad $e s!m!lar a$ara$ #ro)lem on er le'$ eye 'or . years and &en$ 'or a$ara$ s"rgery las$ year No& !$ as )een $rea$ed ?es!des9 se also as )een d!agnosed &!$ D!a)e$es Mell!$"s 'or 3 years %er "s"al 'as$!ng )loos s"gar le;el meas"red )e'ore )rea2'as$ !s = mmol04 Se !s om#l!an$ $o $e med!a$!on and "rren$ly on reg"lar 'ollo& "# a$ (l!n!2 (es!a$an O$er $an $a$9 se !s also d!agnosed &!$ y#er$ens!on and dysl!#!dem!a s!ne 5 mon$s ago Se !s om#l!an$ $o $e med!a$!on 'or )o$ and also on reg"lar 'ollo& "# a$ (l!n!2 (es!a$an
PAST S@RGICA4 %ISTOR8 •
•
In -119 se "nder&en$ 'or ar)"nle s"rgery $&!e d"e $o "non$rolled d!a)e$es B s"ess'"l &!$o"$ any #os$< o#era$!;e om#l!a$!ons In O$o)er -1,=9 se ad a a$ara$ remo;al s"rgery on er le'$ eye9 done !n %os#!$al B s"ess'"l &!$o"$ any #os$< o#era$!;e om#l!a$!ons
DR@GS AND A44ERG8 %ISTOR8 C"rren$ly se !s on a 'e& med!a$!ons 'or d!a)e$es9 y#er$ens!on and dysl!#!dem!a &! are: • • • • • • •
T Cl!la!de B 1mg OD )e'ore )rea2'as$ T As#!r!n .11mg OD T S!m;as$a$!n -1mg T T&yns$a *$elm!sar$an and amlod!#!ne+ T Me$'orm!n < / $a)le$s a$ n!g$ SC Ins"la$ard -1 "n!$s a$ n!g$ SC A$ra#!d "n!$s !n $e morn!ng
?es!des9 se &as on omeo#a$y med!a$!on 'or - years and reenl$ s$o##ed s!ne se &as adm!$$ed $o $e &ard O$er&!se9 se as no 2no&n allerg!es $o 'ood or o$er dr"gs
FAMI48 %ISTOR8
• •
•
•
Ms Z !s $e seond o"$ o' er 7 s!)l!ngs ?o$ o' er #aren$s ad #assed a&ay er la$e 'a$er d!ed d"e $o s$ro2e a$ $e age o' 53 &!le er la$e mo$er d!ed $o om#l!a$!ons o' d!a)e$es and renal d!sease %er elder s!s$er as y#er$ens!on and er $&o yo"nger s!)l!ngs )o$ are d!a)e$! %er las$ . s!)l!ngs are $ and eal$y O$er&!se9 $ere !s no !s$ory o' mal!gnany l!2e )ra!n aner r"ns !n $e 'am!ly
SOCIA4 %ISTOR8 •
• • •
Ms Z !s a &!do& and "rren$ly l!;es &!$ er . !ldren !n a s!ngle
PHYSICAL EXAMINATION
GENERA4 EAMINATION Pa$!en$ &as s!$$!ng om'or$a)ly on er )ed Se &as aler$9 ons!o"s and &ell or!en$ed $o $!me9 #lae and #erson ID $ag &as #resen$ on er le'$ &r!s$ Se &as no$ !n res#!ra$ory d!s$ress9 no s!gns o' #allor or a"nd!e Se &as large )"!l$ &!$ good ydra$!on and n"$r!$!onal s$a$"s
HITA4 SIGNS P"lse ra$e
: 1 )ea$s0m!n9 reg"lar ry$m9 good ;ol"me &!$ normal ara$er
Res#!ra$ory ra$e
: , )rea$s0m!n *normal+
?lood #ress"re
: ,.507 mm%g *y#er$ens!;e+
Tem#era$"re
: .71 C *a'e)r!le+
>e!g$
: 35 2g
%e!g$
: ,== m
?MI
: ./ 2gm<-
OC@4AR EAMINATION ,+ HIS@A4 AC@IT8 Right eye
$o
Left eye
Visual acuity
A)le
reogn!e =0=
Near visual acuity
and mo;emen$ <
Good
-+ INSPECTION Tere &as no syndrom! 'ea$"re on #a$!en$’s 'ae •
Right eye
Left eye
Re re!e" Li
A)sen$ No #$os!s
Presene and No #$os!s and s&ell!ng
Eye #$siti
%$s&ell!ng 4!g$ 'ell on $e #"#!l 4!g$ 'ell on $e en$re
C$%&u%ctiva C$r%ea A%teri$r
marg!n $em#orally >!$e9 no$ !ne$ed Clear Normal *dee#+
o' #"#!l >!$e9 no$ !ne$ed Clear Normal *dee#+
cha'(er Pu#il
Normal
<
Irreg"lar
*o;al
!n
sa#e+ < Presene o' . s$!$es a$ ,19 ,, and ,- o’lo2 #os!$!on < Presene o' &!$!s !n!s!onal &o"nd sar a$ $e a)o;e #"#!llary marg!n
O#a6"e P@PI44AR8 EAMINATION
Le%s
.+
Pse"do#a2! lens
Right eye
Left eye
)irect re!e" C$%se%sual
A)sen$ Presen$
Presen$ Presen$
*i%irect+ re!e" RAP)
Nega$!;e
Nega$!;e
/+
DIRECT OP%TA4MOSCOP8 Right eye
,i%i%gs
•
Te '"nd"s anno$ )e
Left eye •
>ell dened o#$!
•
d!s o"$l!nes Colo"r o' o#$! d!s !s
•
#!n2 Ra$!o o' o#$! d!s $o
•
o#$! "# !s 1. ?lood ;essels are
a##re!a$ed d"e $o $e #resene o' a$ara$
• •
seen Ma"la !s seen No eJ"da$es9 aemorrage or a)normal!$!es seen
5+
ETRAOC@4AR MOHEMENT • •
4e'$ eye an mo;e !n all d!re$!on R!g$ eye an mo;e !n all d!re$!on eJe#$ $o $e r!g$ la$erally
=+
HIS@A4 FIE4D • •
4e'$ eye an see all / 6"adran$s &!$o"$ )l"rr!ng o' ;!s!on R!g$ eye ;!s"al eld anno$ )e $es$ed d"e $o a$ara$
7+
S4IT<4AMP EAMINATION &as no$ done
+
TONOMETR8 &as no$ done
CRANIAL NERVE EXAMINATION 5$ ran!al ner;e: Tr!gem!nal ner;e •
sensory : normal
•
reKeJ
: normal
7$ ran!al ner;e: Fa!al ner;e • • •
no 'a!al asymme$ry no #aro$!d enlargemen$ "##er and lo&er mo$or ne"ron are !n$a$
$ ran!al ner;e : Hes$!)"lar
•
ear!ng !s e6"al a$ )o$ ears
S@MMAR8 Ms Z9 a 57
PROHISIONA4 DIAGNOSIS Right si"th cra%ial %erve #alsy sec$%ary t$ u%c$%tr$lle ia(etes-
S"##or$!ng #o!n$s:
Se &as no$!ed )y er son $a$ se o"ld no$ mo;e er
r!g$ eye $o $e r!g$ On eJam!na$!on9 #a$!en$ o"ld no$ #er'orm a)d"$!on o'
$e r!g$ eye9 )"$ add"$!on &as done ;ery &ell Pa$!en$ as m"l$!#le "nderly!ng 'a$ors: d!a)e$es mell!$"s 'or 3 years and as a !s$ory o' ar)"nle remo;al s"rgery $&!e !nd!a$!ng "non$rolled d!a)e$es ?es!des9 se as )een d!agnosed &!$ y#er$ens!;e and dysl!#!dem!a as &ell
DIFFERENTIA4 DIAGNOSIS *A+ S!J$ ran!al ner;e les!on d"e $o )asal s2"ll 'ra$"re •
POINTS S@PPORTING @na)le $o mo;e r!g$ eye $o $e r!g$
•
POINTS AGAINST No !s$ory o' $ra"ma $o $e 'ae or eye
*?+ Cere)ello<#on$!ne $"mor or me$as$ases POINTS S@PPORTING •
@na)le $o mo;e r!g$ eye
POINTS AGAINST •
$o $e r!g$
No s!gns o' mal!gnany s" as loss o' a##e$!$e9
•
loss o' &e!g$ No !s$ory o' #r!mary
•
mal!gnany No s!gns o' !m#a!red 7 $ and $ ran!al ner;es
*C+ A"$e ;!ral men!ng!$!s •
POINTS S@PPORTING @na)le $o mo;e r!g$ eye
•
$o $e r!g$ Pa$!en$ !s a'e)r!le ene
•
POINTS AGAINST No !s$ory o' reen$
•
!n'e$!on No s!gns o' men!ng!$!s l!2e
•
se!"re and #o$o#o)!a Men!ng!$!s $ends $o a"se
;!ral !n'e$!on !s #oss!)le
)!la$eral ner;e #alsy
MANAGEMENT Pro#osed !n;es$!ga$!ons: •
•
•
•
•
,ull (l$$ c$u%t *,.C+ B $o loo2 'or s!gns o' !n'e$!on and
anem!a 'rom $e &!$e ell o"n$ and emoglo)!n le;el res#e$!;ely H(A/c level B $o ens"re &e$er #a$!en$’s d!a)e$es !s on$rolled s!ne $e las$ . mon$s ,asti%g (l$$ sugar *,.S+ < $o e2 &e$er #a$!en$’s )lood s"gar !s on$rolled Re%al fu%cti$% test B $o e2 'or Crea$!n!ne le;el as a s!gn o' d!a)e$es om#l!a$!on 0ri%e ,EME *0,EME+ B $o loo2 'or #resene o' al)"m!n"r!a as a s!gn o' d!a)e$es om#l!a$!on
PROPOSED TREATMENT •
•
•
Pa$!en$ !s adm!$$ed $o $e eye &ard !n order $o on$rol er )lood s"gar s!ne d!a)e$es !s $e #r!mary a"se o' $e #alsy Plan $e r!g$ $!me 'or #a$!en$’s r!g$ eye a$ara$ s"rgery only a'$er $e a)d"ens ner;e #alsy !s $o$ally $rea$ed One se !s d!sarged9 #a$!en$ needs $o on$!n"e $a2!ng er med!a$!ons 'or d!a)e$es9 y#er$ens!on and dysl!#!dem!a and ome 'or reg"lar 'ollo& "# $o ens"re er ond!$!on !s s$a)le and "nder on$rol
INTERNATIONAL ME)ICAL SCHOOL MANA1EMENT 2 SCIENCE 0NIVERSITY ROTATION 34 OPHTHALMOLO1Y CASE 5RITE 0P NAME
: SITI N@R ?AITI ?INTI S%AI( (%AMAR@DIN
COORDINATOR DATE
DISC@SSION
: DR (%AING : .RD APRI4 -1,7
Cran!al ner;e HI9 also 2no&n as $e a)d"ens ner;e9 !nner;a$es $e !#s!la$eral la$eral re$"s *4R+9 &! '"n$!ons $o a)d"$ $e !#s!la$eral eye Te s!J$ ner;e n"le"s !s loa$ed !n $e #ons9 "s$ ;en$ral $o $e Koor o' $e 'o"r$ ;en$r!le and "s$ la$eral $o $e med!al long!$"d!nal 'as!"l"s *M4F+ Pa$!en$s "s"ally #resen$ &!$ )!no"lar or!on$al d!#lo#!a *do")le ;!s!on #rod"!ng a s!de<)y
REFERENCE , ?rad ?o&l!ng O"lar Mo$or Ner;es Kanski – Clinical Ophthalmology A Systemic Approach, Eighth Edition. -1,=
Ca#$er ,3: Ne"ro