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The Fundus, Again!

Topic: Adult

Created on Saturday, November 8 2008 by rednucleus

Last modified on Saturday, November 8 2008.

A 41-year-old man has been referred by his GP as difficult-to-manage headache for the past 2 years. His GP says I’m concerned about his fundal appearance. Examination is totally unremarkable but his fundoscopy shows 2 left-sided whitish patches with black irregular margins, over which the retinal arterioles cross. His bloods, brain gadolinium MRI, and CSF are normal. What would you tell his GP?

A) Do visual evoked potentials

B) Ignore his fundal appearance

C) Arrange for brain CT scan with contrast

D) Do HIV serology

E) Re-MRI after 3 months

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This question was created on November 08, 2008 by rednucleus.
This question was last modified on November 08, 2008.

ANSWERS AND EXPLANATIONS

A) Do visual evoked potentials

This answer is incorrect.

He has no visual features, and the history is not biased towards multiple sclerosis so as to detect sub-clinical optic nerve involvement. (See References)


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B) Ignore his fundal appearance

This answer is correct.

The fundoscopic findings are suggestive of “old choroiditis;” this is a rather common incidental finding, mostly due to old subclinical toxoplasmosis, which has no relation with the chronic “tension” type headache in our patient. Neurologists do fundoscopy many times a day at work, and it is very likely that they encounter normal variants (like optic nerve head drusen, myelinated nerve fibers) or incidental benign findings unrelated to the patient’s disease (like ours). (See References)


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C) Arrange for brain CT scan with contrast

This answer is incorrect.

The contrast brain MRI is already normal-looking; why doing CT?! (See References)


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D) Do HIV serology

This answer is incorrect.

Neither the complaint nor the fundal appearance are pointing towards HIV infection. (See References)


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E) Re-MRI after 3 months

This answer is incorrect.

The brain imaging and CSF examination are normal; there is no advantage of re-doing the MRI after an interval. (See References)


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References:

1. Victor, M., and Ropper, A.H. (2001). Adams and Victor's Principles of Neurology, 7th Edition. McGraw-Hill, New York. (ISBN:0070674973)

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adult
The Fundus, Again!
Question ID: 110808076
Question written by rednucleus. (C) FrontalCortex.com 2006-2009, all rights reserved. Created: 11/08/2008
Modified: 11/08/2008
Estimated Permutations: 120