Nervous System & Special Senses


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M57_F1.jpg"}},{"insert":"\n\n"},{"insert":"It\u0027s almost lunchtime. You\u0027ve seen a steady stream of patients throughout the morning, most of whom just had seasonal flu.\n\n\u0022I\u0027ll be sending in the last patient now\u0022, your nurse says.\r\n\r\n\u0022.... and then I can have lunch\u0022, you think.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M57_F2.jpg"}},{"insert":"\n\n"},{"insert":"Susan, a 26-year-old postgraduate student looks visibly frightened.\r\n\r\n\u0022Doctor! My eyes started hurting when I woke up today. Everything seems blurred and all colors are off!\u0022.\n"}]}


{"ops":[{"insert":"Her words make you sit up straight. Feeling concerned, you ask several follow up questions.\r\n\r\nThis is the first time Susan has experienced these symptoms. Close questioning reveals that she has been feeling tired and fatigable for the last 2 weeks. No other symptoms are present.\n\nShe has been in perfect health until now and is not on any medications, including over-the-counter drugs, herbal medications, or supplements.\r\n\r\nHer family history is unremarkable. She only drinks socially and has never smoked or used recreational drugs.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M57_F4.jpg"}},{"insert":"\n\n"},{"insert":"On inspection, both eyes look normal. However, the pupillary light reaction appears to be diminished in the right eye, while visual acuity is 20\/30 in the left eye but only 20\/50 in the right eye.\r\n\r\nConfrontation, ocular motility testing, and fundoscopy are all normal. The remainder of the examination is also normal.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M57_F5.jpg"}},{"insert":"\n\n"},{"insert":"Feeling even more concerned, you write out an urgent referral to the ophthalmology clinic and ask Susan to go there and come back to your office once done.\r\n\r\nWhile she is away, you take the opportunity to gulp down a quick lunch.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M57_F6.jpg"}},{"insert":"\n\n"},{"insert":"Almost two hours later, Susan is in front of you once more. You quickly review the results of the\u00a0ophthalmology referral.\n\nSlit lamp examination showed no abnormalities. However, perimetry revealed a central scotoma and altitudinal and arcuate defects of the visual field of the right eye.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M57_F7.jpg"}},{"insert":"\n\n"},{"insert":"The ophthalmologist took it on himself to order an urgent cranial MRI as well. This showed a demyelinating plaque of the right optic nerve.\r\n\r\nHis diagnosis is optic neuritis, and he has started Susan on a course of corticosteroids. She will be admitting herself to the hospital once done speaking to you.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M57_F6.jpg"}},{"insert":"\n\n"},{"insert":"\u0022Thank you so much, doctor. The ophthalmologist explained everything, and stressed that I\u0027m lucky that we caught the problem so quickly\u0022, Susan says.\r\n\r\n\u0022But I didn\u0027t quite understand one thing - what exactly is the disease I have?\u0022\n"}]}