Case presentationCase presentation

Intern 雲智謙

Basic dataBasic data

Age: 44Sex: femaleMarital status: MarriedDate of admission: 2010/8/13Chart No. 26227497

Chief ComplaintChief ComplaintBilateral blurred vision for about

half year

Present illnessPresent illnessThis patient is transffered from neurology

ward. Tracing back her history, she had blurred vision since for more than 6 months. Due to no other associated symptom and there was no bothering of her life, she didn’t pay much attention to this problem until this July when her vision get suddenly worse.

According to her statement, she had much severe blurred vision of bilateral eyes, and 兩行字會混一行 . She also had photophobia sometimes and metamorphopsia. She denied tinnitus, dizziness, headache, diplopia , floaters and lactation.

Present illnessPresent illnessDue to the above problems, she ever

went to 萬芳 H oph. for help where right retina tear without detachment was diagnosed and laser therapy was done twice there. (7 月中 )

After that, the problem of blurred vision was still not improved, she then saught for other oph. clinics for help in Kaohsiung where 眼球積水 was impressed and eye drop was given. Due to no obvious improvement, she was suggested to seek medical center.

Present illnessPresent illnessShe then came to KMU neurology

OPD for help and due to bilateral temporal hemianopsia and non-cyclic menstral period, she was arranged VEP, MRI.

She was then transferred to Neurology ward and the brain MRI had positive finding, so she was transferred to our ward for surgical intervention.

Past historyPast history• Diabetic Mellitus : denied• Hypertension: denied• Dyslipidemia : +• Operation history:

• surgery for hemorrhoid 10+ years ago• Laser and FAG for retinal tear

Personal and social historyPersonal and social historyCigarette Smoking : deniedAlcohol : deniedBetel nut: deniedOccupation history : housekeeperContact history : deniedTravel history : long lived in

mainland ChinaFamily history: not contributoryAllergy history: denied

Physical examinationPhysical examination Consciousness: alert, E4V5M6 Vital sign:BP: 111/80 mmHg, PR: 72 bpm, RR: 20 cpm,

BT: 36 ℃ HEENT: conjuctiva: not pale, sclera: not icteric, throat:

not injected Neck: supple lymphadenopathy(-), jugular vein engorgement(-)

thyroid: impalpable Chest: spider angioma(-) symmetric expansion, accessory muscle usage(-) breathing sound: bilateral clear Heart: thrills(-), regular heart beat Abdomen: soft and flat, no tenderness liver/spleen: impalpable bowel sound: normoactive extremity : no pitting edema Skin: no rash

Neurological examinationNeurological examinationMENTAL STATUS

◦ Consciousness: alert and clear, GCS:E4V5M6◦ Speech: well performance◦ JOMAC: ok

Crnanial Nerves◦ I: not test◦ II: visual acuity: intact, visual field: bilateral hemianopsia, ◦ III,IV,VI: pupils: 3/3 mm, light reflex: (+/+), EOM: free, nystagmus(-), diplopia(-), ptosis(-)◦ V: facial sensation: intact◦ VII: no facial palsy, corneal reflex: (+/+)◦ VIII: intact◦ IX,X : uvula postion: central, gag reflex:(+/+)◦ XI: SCM, Trapezius: intact◦ XII: tongue atrophy(-), tongue deviation(-)

Motor Function◦ muscle tone: normal tone◦ M.P.:(0-5)

upper proximal distal lower proximal Distal

◦ DTR: (0-++++) Biceps reflex Brachiaradialis Knee jerk Ankle jerk

◦ Plantar response: plantar reflex / plantar reflex

R’t L’t5 55 55 55 5

R’t L’t++ ++++ ++++ ++++ ++

Coordination and Gait◦ Coordination:

Finger-nose-finger (FNF): fair Heel-knee-shin (HKS): fair

◦ Gait: fair

Sensory Function◦ Pin-prick: not test◦ Vibration: not test ◦ Light touch: not test

Lab Lab datadata

Lab data

Image and ImpressionImage and ImpressionArrange brain MRI Impression: pituitary

macroadenoma with cystic degeneration and suprasellar extension (2.3x1.9x4.2cm)

Differential diagnosisDifferential diagnosis

Thank youThank you

Visual fieldVisual field

8/13 VEP reportImpaired visual conduction, both

eyesPlease make clinical correlation