one for the medics here....
Discussion
hi guys, looking at a past paper question for my neuro-orthopaedics modules and struggling for diagnoses and wondering if some of the clever guys here might be able to help.... here goes.
[b]A 29-year-old female secretary comes to the clinic complaining of headaches and visual blurring of 3 months duration. It appears to be getting worse and the headaches are mostly noticed in the morning although they don't seem to wake her up.
She often has take-away meals and drinks a fair amount of alcohol at parties. She is on the contraceptive pill but does otherwise not take any medication apart from vitamin supplements. She is quite obese and does not exercise on a regular basis but enjoys Saturday nights out with her female friends.
On physical examination her blood pressure is moderately raised and fundoscopy reveals papilloedema. No signs of focal lesions are found, light reflexes and corneal reflexes are normal. The remainder of the examination is normal.
What are your differentials in this age group and gender as opposed to an obese girl of 9 years of age with similar symptoms and moderately - high blood pressure. papilloedema and a clumsy arm?
Briefly discuss and critically reflect upon which aetiologies might be considered here and why.
Which clinical signs would you consider important to investigate or look for in the context of her current symptoms in order to come up with the most likely diagnosis and at least one differential diagnosis? Which further investigative procedures would be most relevant and why?[/b]
so far i was thinking papilloedema suggests raised intracranial pressure, but the 3 months duration rules out haemorrhage, so possible neoplasm (e.g. astrocytoma...???) or abscess., which could also explain the "clumsy arm". uncontrolled diabetes (could be type 1 in the 9 year old, uncontrolled type 2 in 29 year old...mellitus of course) could cause diabetic retinopathy (hence the fundoscopy findings) as well as headaches, possibly causing the headaches in the morning due to hypoglycaemia. other than a neoplasm again for the 9 year old i'm struggling to come up with differentials, diabetic etc doesn't explain the clumsy arm, perhaps some cerebellar lesion might...bearing in mind it appears to be only unilateral though.
as her BP is only moderately high, temporal arteritis and severe hypertension ruled out (and no findings of temporal arteritis mentioned on physical exam)
If anyone can help, thanks very much. if not, i don't blame you
[b]A 29-year-old female secretary comes to the clinic complaining of headaches and visual blurring of 3 months duration. It appears to be getting worse and the headaches are mostly noticed in the morning although they don't seem to wake her up.
She often has take-away meals and drinks a fair amount of alcohol at parties. She is on the contraceptive pill but does otherwise not take any medication apart from vitamin supplements. She is quite obese and does not exercise on a regular basis but enjoys Saturday nights out with her female friends.
On physical examination her blood pressure is moderately raised and fundoscopy reveals papilloedema. No signs of focal lesions are found, light reflexes and corneal reflexes are normal. The remainder of the examination is normal.
What are your differentials in this age group and gender as opposed to an obese girl of 9 years of age with similar symptoms and moderately - high blood pressure. papilloedema and a clumsy arm?
Briefly discuss and critically reflect upon which aetiologies might be considered here and why.
Which clinical signs would you consider important to investigate or look for in the context of her current symptoms in order to come up with the most likely diagnosis and at least one differential diagnosis? Which further investigative procedures would be most relevant and why?[/b]
so far i was thinking papilloedema suggests raised intracranial pressure, but the 3 months duration rules out haemorrhage, so possible neoplasm (e.g. astrocytoma...???) or abscess., which could also explain the "clumsy arm". uncontrolled diabetes (could be type 1 in the 9 year old, uncontrolled type 2 in 29 year old...mellitus of course) could cause diabetic retinopathy (hence the fundoscopy findings) as well as headaches, possibly causing the headaches in the morning due to hypoglycaemia. other than a neoplasm again for the 9 year old i'm struggling to come up with differentials, diabetic etc doesn't explain the clumsy arm, perhaps some cerebellar lesion might...bearing in mind it appears to be only unilateral though.
as her BP is only moderately high, temporal arteritis and severe hypertension ruled out (and no findings of temporal arteritis mentioned on physical exam)
If anyone can help, thanks very much. if not, i don't blame you
Edited by E21_Ross on Tuesday 17th May 21:00
I am not a true medic but I do work in oncology, so naturally to me those symptoms can indicate a tumour - such as astrocytoma (as you mentioned), glioblastoma, oligodrendroglioma, meningioma etc - and the brain tumour you are more likely to get as an adult differ to those of a 9yr old. Sorry I can't be of any more help.
AMLK said:
I am not a true medic but I do work in oncology, so naturally to me those symptoms can indicate a tumour - such as astrocytoma (as you mentioned), glioblastoma, oligodrendroglioma, meningioma etc - and the brain tumour you are more likely to get as an adult differ to those of a 9yr old. Sorry I can't be of any more help.
thanks. only brain tumours i could think of off the top of my head were astrocytoma, glioblastoma and ependymoma, so thanks for the others. I think multiple sclerosis could give similar symptoms too... so maybe have that as a differential, but tumour would probably be my main working dx. can't claim to know which occur in what age group so if you could shed more light on that i'd be very grateful 
thanks again,
Ross.
E21_Ross said:
A 29-year-old female secretary comes to the clinic complaining of headaches and visual blurring of 3 months duration. It appears to be getting worse and the headaches are mostly noticed in the morning although they don't seem to wake her up.
She often has take-away meals and drinks a fair amount of alcohol at parties. She is on the contraceptive pill but does otherwise not take any medication apart from vitamin supplements. She is quite obese and does not exercise on a regular basis but enjoys Saturday nights out with her female friends.
On physical examination her blood pressure is moderately raised and fundoscopy reveals papilloedema. No signs of focal lesions are found, light reflexes and corneal reflexes are normal. The remainder of the examination is normal.
What are your differentials in this age group and gender as opposed to an obese girl of 9 years of age with similar symptoms and moderately - high blood pressure. papilloedema and a clumsy arm?
Briefly discuss and critically reflect upon which aetiologies might be considered here and why.
Which clinical signs would you consider important to investigate or look for in the context of her current symptoms in order to come up with the most likely diagnosis and at least one differential diagnosis? Which further investigative procedures would be most relevant and why?
Papilloedema results from raised intracranial pressure in which the subarachnoid space surrounding the optic nerve is patent, i.e. papilloedema is not a necessary consequence of raised intracranial pressure.She often has take-away meals and drinks a fair amount of alcohol at parties. She is on the contraceptive pill but does otherwise not take any medication apart from vitamin supplements. She is quite obese and does not exercise on a regular basis but enjoys Saturday nights out with her female friends.
On physical examination her blood pressure is moderately raised and fundoscopy reveals papilloedema. No signs of focal lesions are found, light reflexes and corneal reflexes are normal. The remainder of the examination is normal.
What are your differentials in this age group and gender as opposed to an obese girl of 9 years of age with similar symptoms and moderately - high blood pressure. papilloedema and a clumsy arm?
Briefly discuss and critically reflect upon which aetiologies might be considered here and why.
Which clinical signs would you consider important to investigate or look for in the context of her current symptoms in order to come up with the most likely diagnosis and at least one differential diagnosis? Which further investigative procedures would be most relevant and why?
e.g.:
intracranial space-occupying lesions:
tumours, especially of the posterior fossa POSSIBLE MUST EXCLUDE
cerebral abscesses POSSIBLE BUT UNLIKELY NOT SICK ENOUGH
subdural haematoma POSSIBLE MUST EXCLUDE
any condition causing hydrocephalus in an adult:
subarachnoid haemorrhage, meningitis, head injury ALL UNLIKELY HISTORY DOES NOT FIT
venous obstruction - especially due to venous sinus thrombosis POSSIBLE, obese & on OCP MUST EXCLUDE
benign intracranial hypertension - most likely in patients with visual complaints but otherwise normal POSSIBLE BUT MUST RULE OUT OTHERS
malignant hypertension - bilateral with other signs of hypertensive neuropathy BP NOT HIGH ENOUGH
central retinal venous occlusion, ischaemic optic neuropathy, optic neuritis - NO unilateral with sudden loss of vision
chronic carbon dioxide retention NO
Other rare causes:
hypoparathyroidism POSSIBLE VERY RARE
diabetic ketoacidosis NO
chronic carbon dioxide retention NO
obesity POSSIBLE BUT MUST EXCLUDE OTHERS
haematological - anaemia, leukaemia NO OTHER SIGNS
toxic - tetracycline, lead, oral progestational agents, corticosteroid withdrawal COULD BE OCP but RARE MUST EXCLUDE OTHERS FIRST
spinal cord tumours, perhaps due to high CSF protein levels NO FOCAL SIGNS
SHE NEEDS URGENT CT (BEST FOR BLEEDS) OR MRI (BEST FOR TUMOURS)
IF NO TUMOUR OR BLEED NEEDS LP
9 YR OLD MORE LIKELY TO HAVE SPACE OCCUPYING LESION DUE TO FOCAL SIGNS. ABSCESS UNLIKELY IN BOTH AS THEY TEND TO BE SICK. EITHER COULD HAVE CHRONIC SUBARACHNOID OR TUMOUR (OF MANY FLAVOURS - POSTERIOR FOSSA MOST PROBABLE).
JOHN
thanks John, much appreciated got my exam in this tomorrow 
just had neuro-ortho osce which wasn't tooooo bad. case was 55 year old male patient with 2 months onset of bilateral arm and leg weakness with no sensory symptoms. on examination i found decreased reflexes bilaterally (pretty much ruling out amyotropic lateral sclerosis), there was no history given about recent infection so couldn't rule out guillain-barre, diabetic/alcoholic/B12 deficiency polyneuropathy possible but unlikely given no sensory symptoms, MS possible but age maybe a bit old, stroke due to occlusion or haemmorhage ruled out due to gradual onset and worsening over 2 months. BP was normal, all myotomes 3/5 bilaterally upper and lower limb, dermatomes normal. gait was normal. no history of headaches, trauma. couldn't rule out chronic fatigue syndrome either, myaesthenia gravis possible but again, a little too old perhaps. cranial nerve exam was also normal.
i thought it was a tough case, considering my mate simply had 60yo female with chronic low back pain with recent onset of buttock pain, no radiations. how much easier is that!! (IMO)
thanks again mate! back to revision
got my exam in this tomorrow just had neuro-ortho osce which wasn't tooooo bad. case was 55 year old male patient with 2 months onset of bilateral arm and leg weakness with no sensory symptoms. on examination i found decreased reflexes bilaterally (pretty much ruling out amyotropic lateral sclerosis), there was no history given about recent infection so couldn't rule out guillain-barre, diabetic/alcoholic/B12 deficiency polyneuropathy possible but unlikely given no sensory symptoms, MS possible but age maybe a bit old, stroke due to occlusion or haemmorhage ruled out due to gradual onset and worsening over 2 months. BP was normal, all myotomes 3/5 bilaterally upper and lower limb, dermatomes normal. gait was normal. no history of headaches, trauma. couldn't rule out chronic fatigue syndrome either, myaesthenia gravis possible but again, a little too old perhaps. cranial nerve exam was also normal.i thought it was a tough case, considering my mate simply had 60yo female with chronic low back pain with recent onset of buttock pain, no radiations. how much easier is that!! (IMO
)thanks again mate! back to revision
shed driver said:
Chiari Malformation? Mrs SD has it and the variety of symptoms could fit any of these.
SD
SD
Arnold-chiari malformation could cause that. you can also get a budd-chiari syndrome but that's something quite different.had exam today and it went really rather well. not as bad as some of the past papers at least! was a lucky barsteward as there was a question on an argyll-robertson pupil...happened to stumble across that at 10pm last night
cheers
My money's on benign intracranial hypertension. These questions are always written in a "textbook" way and headache + papilloedema + obesity + female = BIH in the books. Still need to exclude a SOL, which is the number one differential with the same symptoms in a 9 year old. Needs CT head, then LP to drain CSF. Headache should resolve immediately, but opening pressure is likely to be v high. Last one I did had an opening pressure of 60-something cmH20.
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