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aktorque 03-31-2011 12:49 PM

High Yield Question #1
 
1 Attachment(s)
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:

Attachment 1211
click image to enlarge

A) Retinopathy
B) Open angle glaucoma
C) Closed angle glaucoma
D) Retinoblastoma
E) Normal pressure hydrocephalus

heights 03-31-2011 01:05 PM

B open angle glaucoma.

Not C because closed angle is an acute medical emergency.
Not D because it's a genetic problem so you'd expect it in younger age
E- not sure what visual changes this would present with, but you'd also have ataxia and urinary incontinence.

patelMD 03-31-2011 01:23 PM

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

heights 03-31-2011 02:47 PM

Quote:

Originally Posted by patelMD (Post 33376)
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:)

patelMD 03-31-2011 02:48 PM

Quote:

Originally Posted by heights (Post 33391)
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:)

OH man I completed omitted reading the normal pressure part :o

I haven't gone through the audio yet, hopefully I remember all this hehe

heights 03-31-2011 02:55 PM

Quote:

Originally Posted by patelMD (Post 33393)
OH man I completed omitted reading the normal pressure part :o

I haven't gone through the audio yet, hopefully I remember all this hehe

Yeah, definitely make sure you listen to it! I haven't really sat down and gone through it, but I listen to it while I exercise and some of it really sticks.

aktorque 03-31-2011 06:19 PM

Quote:

Originally Posted by heights (Post 33391)
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:)

nice one...

E) Normal pressure hydrocephalus

Thanks guys for your answers.

It was in my exam and the ans is E) Normal pressure hydrocephalus. They haven't give me the complete history. Just few words about the patient and the picture.

This is a picture of a papilledema due to increase ICP
http://www.health-writings.com/img/u...ve/figure5.jpg
http://www.mayoclinicproceedings.com...1/F4.small.gif
http://pds16.egloos.com/pds/201004/1...c4d0d09a7c.jpg

patelMD 03-31-2011 06:26 PM

Quote:

Originally Posted by aktorque (Post 33410)
nice one...

E) Normal pressure hydrocephalus


http://www.mayoclinicproceedings.com...1/F4.small.gif

That's totally odd.. I related that picture with this:

http://2.bp.blogspot.com/_OkLnqwQYzE...ma+%281%29.jpg http://racheleye.com/images/glaucoma1.gif
(The lighter part being the optic disc)



:rolleyes:

aktorque 03-31-2011 06:32 PM

The one I had isn't that clear like your picz... but this is a very good one picture. Thanks patel MD

heights 03-31-2011 09:04 PM

Quote:

Originally Posted by patelMD (Post 33411)
That's totally odd...



:rolleyes:

Yeah I don't understand how to get to normal pressure hydrocephalus (NCP) based on the question stem either. I thought NCP was chronic, so the ventricles gradually dilate to accommodate the increase CSF production, hence you have normal pressure and not increased intracranial pressure (aktorque's pic with the blood shot eyes is ICP)

I thought B because of the headache and blurry vision; does NCP cause blurry vision? I can see headache, but I don't get how that would cause blurry vision. Please explain :notsure:

apx85 03-31-2011 10:09 PM

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

apx85 03-31-2011 10:12 PM

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"

aktorque 04-01-2011 06:01 PM

Quote:

Originally Posted by apx85 (Post 33438)
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"

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.

heights 04-02-2011 08:17 AM

Quote:

Originally Posted by aktorque (Post 33569)
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.

Hey Aktorque you're a smart one! I went over this with my path teacher yesterday and he said the same thing. For glaucoma, only the entire eye is being pushed out from the inside, with sort of flattening from the inside. With ICP, the optic disc bulges out.

janak 04-05-2011 06:10 AM

Quote:

Originally Posted by heights (Post 33626)
Hey Aktorque you're a smart one! I went over this with my path teacher yesterday and he said the same thing. For glaucoma, only the entire eye is being pushed out from the inside, with sort of flattening from the inside. With ICP, the optic disc bulges out.

i agree with heights if that was the hydrocephalus how did the optic disc turns into the shape of cup. it is most probably the glaucoma due to optic cupping is seen and theres buyonetting sign too look that closely you can see guys

DOCSHO 04-14-2013 06:54 PM

Quote:

Originally Posted by aktorque (Post 33569)
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.

but in normal pressure hydrocephalus there is no elevation of ICT , so you don't see pappiloedema

dr mumble 06-18-2013 12:37 AM

Quote:

Originally Posted by aktorque (Post 33410)
nice one...

E) Normal pressure hydrocephalus

Thanks guys for your answers.

It was in my exam and the ans is E) Normal pressure hydrocephalus. They haven't give me the complete history. Just few words about the patient and the picture.

This is a picture of a papilledema due to increase ICP
http://www.health-writings.com/img/u...ve/figure5.jpg
http://www.mayoclinicproceedings.com...1/F4.small.gif
http://pds16.egloos.com/pds/201004/1...c4d0d09a7c.jpg

are you sure that ther is papiledema in normal pressure hydrocephalus ? i doubt it as no increase in intracranial presure....

bilg 04-08-2016 07:42 AM

correct answer
 
Papillodema dosen't usually occur with NPH. so is this going with chronic open angle glaucoma?


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