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Case presentation

Case presentation. Intern 雲智謙. Basic data. Age: 44 Sex: female Marital status: Married Date of admission: 2010/8/13 Chart No. 26227497. Chief Complaint. Bilateral blurred vision for about half year. Present illness.

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Case presentation

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  1. Case presentation Intern 雲智謙

  2. Basic data • Age: 44 • Sex: female • Marital status: Married • Date of admission: 2010/8/13 • Chart No. 26227497

  3. Chief Complaint • Bilateral blurred vision for about half year

  4. Present illness • This 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.

  5. Present illness • Due 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.

  6. Present illness • She 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.

  7. Past history • Diabetic Mellitus : denied • Hypertension: denied • Dyslipidemia : + • Operation history: • surgery for hemorrhoid 10+ years ago • Laser and FAG for retinal tear

  8. Personal and social history • Cigarette Smoking : denied • Alcohol : denied • Betel nut: denied • Occupation history : housekeeper • Contact history : denied • Travel history : long lived in mainland China • Family history: not contributory • Allergy history: denied

  9. Physical 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

  10. Neurological examination • MENTAL 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(-)

  11. 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

  12. 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

  13. Lab data

  14. Lab data

  15. Image and Impression • Arrange brain MRI • Impression: pituitary macroadenoma with cystic degeneration and suprasellar extension (2.3x1.9x4.2cm)

  16. Differential diagnosis

  17. Thank you

  18. Visual field

  19. 8/13 VEP report Impaired visual conduction, both eyes Please make clinical correlation

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