Mock 11
- Picture for Chickenpox station.
- Picture for
- Abdominal examination for intestinal obstruction should be done in the Simman room.
- Breast mannikin (for Lady with breast lump).
- Urine Dipstick for urinalysis.
3. Bitemporal Hemianopia
Addressing a patient presenting with symptoms suggestive of bitemporal hemianopia involves a focused approach to identify the underlying cause and manage accordingly. This clinical scenario will help IMGs (International Medical Graduates) understand how to handle this complex presentation effectively:
Clinical Scenario: Suspected Bitemporal Hemianopia
Where You Are: Ophthalmology Clinic
Who the Patient Is: A 58-year-old male, Mr. Michael Anderson
Other Information About the Patient: Mr. Anderson has been increasingly bumping into objects, especially noticing issues with peripheral vision. His wife is concerned about his vision changes and accompanied him to the appointment.
Patient Prompts
- Onset: "I started noticing issues a few months ago, but it's gotten worse recently."
- Duration: Gradually worsening over the past several months.
- Progression: "It's becoming more difficult to navigate, especially in crowded places."
- Aggravating Factors: "It's worse in low-light conditions."
- Relieving Factors: "Not really anything; maybe when I focus straight ahead, it feels a bit better."
- Past Medical History: Hypertension, controlled with medication.
- Regular Medications: Lisinopril.
- Allergies: No known allergies.
- Smoking and Alcohol Intake: Non-smoker, occasional alcohol.
- Use of Recreational Drugs: Denies use.
- Occupational History: Accountant.
- Simulated Examination Findings: Visual field testing indicates loss of vision in the outer half of both the right and left visual fields. Normal anterior segment examination, intraocular pressure within normal limits.
Scenario Clinchers
- Patient Concerns: Increasing difficulty with navigation and daily activities; his wife is very worried about his safety.
- Clinchers and Important Points for the Doctors: The pattern of vision loss is consistent with bitemporal hemianopia, often associated with lesions affecting the optic chiasm.
What You Must Do:
- Immediate Actions:
- Reassure the patient and his wife about the steps for further evaluation.
- Explain the importance of identifying the underlying cause of the visual field loss.
- Diagnostic Steps:
- Refer for neuroimaging, specifically MRI of the brain, to evaluate the optic chiasm and surrounding structures.
- Consider blood tests to assess pituitary function if a pituitary adenoma is suspected.
- Referral to Specialists:
- Refer to a neurologist or neuro-ophthalmologist for further evaluation and management based on the MRI results.
Differential Diagnosis
- Pituitary adenoma
- Craniopharyngioma
- Meningioma
- Stroke affecting the optic pathway
Typical Question to Rule Out Differentials: "Have you experienced any other symptoms like headaches, changes in smell or taste, or any hormonal imbalances that might indicate a pituitary issue?"
Red Flags
- Rapid progression of visual field loss.
- Associated symptoms such as headache, nausea, or vomiting.
Actions Doctor Should Do
- Conduct thorough visual field testing to confirm the pattern of vision loss.
- Order immediate neuroimaging to investigate potential causes.
- Assess for other neurological symptoms that may guide further diagnostic testing.
Referral Needs
- Type of Referral: Urgent referral to neurology or neuro-ophthalmology.
- Reason for Referral: Evaluation and management of potential central nervous system pathology causing the bitemporal hemianopia, which may require urgent intervention.
This structured approach ensures a comprehensive evaluation of a patient with suspected bitemporal hemianopia, prioritizing immediate diagnostic steps and specialist referrals to address this potentially serious condition.