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High Yield Question #1

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18K views 17 replies 8 participants last post by  bilg 
#1 ·
65 y/o woman complaints 3 months history of headache and blurry vision. Temp 37c, pressure 135/80 mmHg, P 98, no fever, rash and SOB. Fundoscopy was done, picture shown:

Hair Head Plant Eye Fruit

click image to enlarge

A) Retinopathy
B) Open angle glaucoma
C) Closed angle glaucoma
D) Retinoblastoma
E) Normal pressure hydrocephalus
 
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#4 ·
B Sounds right..

First thought of Retinoapthy, without looking at hte pictures / choices.. but then I realized the button appearance is characteristic of open angle.

E) Hydrocephalus doesn't make sense, because this woman is 65 lol
Good to know about the button appearance, I didn't know that and don't remember seeing a picture like that. I kinda thought it wasn't retinopathy because I associate that with retinal blood vessels (like in diabetic retinopathy)...but I don't understand retinopathy that well.

Note that E is normal pressure hydrocephalus, which is a disease of the elderly (Goljan said his mother has it). It relates to overproduction of CSF so you get dilated ventricles and loss of frontal lobe tissue leading to dementia, which Goljan's mom also has. You can put in a shunt to drain the excess fluid, but in his mom's case they didn't do it because it was too risky, and the pressure eventually normalizes anyway.

(I wish I could remember the important stuff he says the way I remember his little stories :rolleyes:)
 
#11 ·
This question tests our understanding of the various abnormal fundoscopic findings.

This fundoscopy is consistent with papilledema, a sign of increased intracranial pressure. The only answer choice that can cause this of the choices given is E, normal pressure hydrocephalus.

Retinopathy is not likely because it would not be associated with headache. Additionally, fundoscopic findings in retinopathy are usually of hemorrhage, fluffy spots (cotton-wool spots), occluded vessels, or neovascularization

Glaucoma is not possible because in glaucoma, the optic disc margins are still visible! This is the key to ruling out B&C. Cerebral edema causes these margins to be blurred, as in this case. The key in glaucoma is an increased cup/disc ratio. The cup is the inner, brighter area and the disc is the outer, more translucent ring. A cup disc ratio greater than about 0.5, then think glaucoma (the bright part should be less than half the diameter of the dimmer part)

Finally D, Retinoblastoma would present with a mass on the retina, plus this patient is not in the right age group.

So we are left with E, normal pressure hydrocephalus. It is not an ideal answer choice because this is not a typical presentation, I would have liked to see gait disturbance, dementia, or urinary incontinence. But the key here is realizing that even though the pressure measured by LP is normal, the increased fluid is still putting pressure on the brain and this is the reason for the classical symptoms associated with NPH.

This is actually a classic presentation of a brain tumor. When we had our ophtho block, we learned that headache + papilledema is most likely to be a brain tumor and this patient fits that description. I would have liked to see some sort of brain tumor as an answer choice, but unfortunately none was given.

Hope that helps
 
#12 ·
Just found this:

"Impaired absorption of CSF is the suspected mechanism in most cases of secondary normal pressure hydrocephalus (NPH). The most common identified underlying causes are intraventricular and/or subarachnoid hemorrhage (either from aneurysm or trauma) and prior acute or ongoing chronic meningitis (from infection, cancer, or inflammatory disease). Paget disease at the skull base, mucopolysaccharidosis of the meninges, and achondroplasia are other rarely reported causes of NPH"
 
#13 ·
yes you are absolutely right. This qn is basically testing your knowledge of what causing or what is Papilledema.

Papilledema is caused by too much CSF accumulate in the ventricles and optic nerve sheath. As the optic nerve sheath is continuous with the subarachnoid space of the brain (and is regarded as an extension of the central nervous system), increased intracranial pressure is transmitted through to the optic nerve. This will cause optic disc swelling.
 
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