Cim Adem Rough Draft
Cim Adem Rough Draft
Cim Adem Rough Draft
Encephalomyelitis
Source: Mother
% Reliability: 90%
Patient’s Profile:
D.S. is an 11-year old female, Roman Catholic, Filipino student living in San
Vicente, Liloan, Cebu and was admitted for the first time at the Cebu Velez
General Hospital last July 16, 2019 due to loss of vision in the right eye
Pre-natal:
Mother was 25 years old with an OB score of G 4 P 3 (2103) at the time of
pregnancy. First prenatal checkup was done at 4 months AOG conducted by an
obstetrician at Chong Hua Hospital. Mother was diagnosed with gestational
diabetes (highest recorded FBS = 150 mg/dL) and was managed with insulin with
unrecalled units, with which she took with good compliance. Subsequent prenatal
checkups were done regularly. She was prescribed with iron, folic acid, and
calcium supplements (dosage and frequency unrecalled), taken with good
compliance. Mother was non-hypertensive and had no other illnesses during
pregnancy. She is a non-smoker and non-alcoholic drinker. Blood type is A
positive.
Natal:
Patient was born a full term, live, female neonate with good cry and
spontaneous movements via normal spontaneous delivery, after 8 hours of labor
in CHH assisted by an obstetrician, BW = 2720 g. BCG vaccine, hepatitis B
vaccine, vitamin K, and Erythromycin eye ointment were administered at birth.
Patient was noted to be jaundiced after 24 hours of birth. Jaundice resolved with
phototherapy, and was discharged a week after. . No meconium staining, no cord
coil. Birth rank is 4/8.
Postnatal:
Patient’s newborn screening results were normal. Patient was exclusively
breastfed for 3 months; supplementary feeding with milk formula (dilution 1:1) was
started at 3 months old and given until 1 year of age; infant cereal was introduced
at 4 months. Mother claims complete immunization coverage for 1 year given by
their private pediatrician, exact immunizations unrecalled. Patient took
multivitamins and Vitamin C supplements daily
Developmental Milestones
● Smiles at 2 months
● Able to sit without support at 7 months
● Able to stand at approximately 7-8 months
● Scribble and wave goodbye at 10 months
● Respond to name at 11 months
● Walk without support, say first real word and 2-word sentences at 1 year
● Runs at 1 and ½ years
● Write the alphabet at 3 years
Personal-Social
Patient sleeps at least 9 hours per night. Water intake is approximately 6
glasses per day; urinates 3 times a day and defecates 3-4 times a week. No
previous hospitalizations. No history of childhood illnesses. No food and drug
allergies. Patient lives with 7 people at home, all of them apparently well. Primary
care provider is her mother. Food is usually prepared by the household helper.
Source of water is mineral water for drinking, and tap water for food preparation
and other purposes. Patient is currently a grade 5 student, and has always had
good school performance. She also interacts well among her peers.
Heredofamilial Diseases
Heredofamilial diseases include type 2 diabetes mellitus (mother), rheumatic
heart diseases (grandmother), and hypertension on the maternal side; father is
hypertensive. Siblings and other members of the family do not present with
neurologic deficits, similar symptoms or complaints with patient.
History of Present Illness
Two days PTA, cough and coryza persisted, this time associated with fever of
undocumented temperature. She was given paracetamol (Calpol), dose
unrecalled, with partial relief.
One day PTA, patient noted presence of black spots equally distributed on all
visual fields on her right eye which obscured her vision immediately upon waking
up. Symptoms persisted throughout the day, were tolerated and patient proceeded
with daily activities. On the afternoon of the same day, patient was noted to have
unusual gait, somewhat leaning towards her right and easily losing balance. There
was no associated headache, dizziness, nausea or fever. No history of trauma
.
On the day of admission, patient had a complete loss of vision in her right eye,
not associated with pain or foreign body sensation. Gait continued to be unstable.
No changes in sensorium, no speech deficits, no dystaxia. Patient sought consult
from an optometrist and was referred to a neuro-ophthalmologist who advised
patient to undergo MRI and admission at CVGH.
Physical Examination
General Survey: Examined an awake, responsive, afebrile, patient not in
respiratory distress with the following vital signs:
HEENT:
● Normocephalic head, well distributed thick wavy black hair, no deformities, nontender
● Symmetric eyes, no lesions, no discharges, white sclera, moist cornea, pink palpebral conjunctiva,
IOP firm by digital palpation, visual acuity and visual fields are intact on left eye, but (-) on the right
eye
● No nasal discharge, septum at midline
● Pink oral mucosa, no lesions, tongue at midline at rest and on protrusion
CVS: Adynamic precordium, distinct S1 and S2, regular rhythm, normal heart rate
of 75 bpm, no murmurs
Cerebral: Coherent, able to solve simple math problems, oriented to time, and date, remembers name,
and recognizes family
Cranial Nerves:
● II&III: (+)PLR Left eye; (-)PLR right eye; (+)RAPD and (-) light perception right eye
● III, IV, & VI: Full ROM by finger following test
● V: (+)Corneal reflex; intact facial sensation; muscles of mastication strong
● VII: Symmetrical facial features
● VIII: Able to hear via whispered voice test
● IX&X: (+) gag reflex
● XI: Can shrug shoulders equally against resistance
● XII: Tongue at midline at rest and on protrusion
Motor: Good muscle tone; 5/5 muscle strength on all extremities; sudden involuntary shrugging of right
shoulder noted
Cerebellum: Able to perform finger-to-nose test, heel-to-shin test, and rapid alternating movements, but
unable to tandem walk
Reflexes:
Approach to unilateral vision loss in children
To achieve clear vision, light must follow an unhindered path from the front to the back of the eye, traveling through the cornea,
aqueous humor, lens, and vitreous humor to the retina. Refracted by the cornea and lens (and perhaps also by glasses or contact
lenses), light is focused onto the retina where it is transformed into an electrochemical signal by photoreceptors and supporting cells.
The signal is transmitted via the optic nerve through the visual pathways to the occipital lobes.
Alterations in function of any of the structures along the visual pathway may cause vision loss. Pathology can be broadly
divided into three major anatomic categories:
1. Visual media problems – Disorders of the cornea, anterior chamber, lens, and vitreous
2. Retinal problems – Vascular occlusion, retinal detachment, and retinal tumors
3. Neurovisual problems – Optic nerve, chiasmal, and retrochiasmal pathology
TO BE EDITED
Focusing on Neurovisual problems:
A detailed examination is critical to the accurate identification of an optic neuropathy or ocular disorder producing acute visual
loss. Reduced central visual acuity may occur with both optic nerve and ocular conditions, both of which must be considered when
acuity cannot be corrected by pinhole or refraction. Color vision (which can be assessed with pseudoisochromatic color plates or by
testing for perceived color desaturation) is often disproportionately affected by an optic neuropathy.
The hallmark of a unilateral optic neuropathy is the relative afferent pupillary defect (RAPD). The RAPD is determined by
the swinging flashlight test, during which light is alternately directed toward each pupil. When light is directed toward the unaffected
eye, both pupils should constrict normally. When light is shined into the affected eye, the dilation of both pupils indicates the presence
of a RAPD. In a more subtle RAPD, when the affected eye is stimulated the pupils may initially constrict but demonstrate a quicker
redilation. While a small RAPD may be observed in the setting of moderate or severe retinal dysfunction, it is often readily apparent
with even mild unilateral or asymmetric optic neuropathy.
The appearance of the retina and optic disc provides critical information regarding the likely cause of acute monocular visual
loss. A detailed retinal examination following pharmacologic pupillary dilation may reveal evidence of vitreous hemorrhage, retinal
arterial or venous infarction, retinal detachment, or other macular pathology. The optic nerve head should be assessed for signs of
swelling, pallor, or normal appearance. Optic disc swelling in a patient with acute monocular visual loss may indicate ischemia or
inflammation of the optic nerve head. A normal optic disc is expected with retrobulbar processes, such as typical optic neuritis.
Optic disc pallor would indicate chronic compression or prior optic nerve injury, but these are unlikely to present with acute visual loss
unless the patient had unrecognized subclinical injury. When the retina and optic disc appear normal in the setting of acute visual
loss, the identification of a retrobulbar optic neuropathy relies heavily on determining the presence of a RAPD.
MOST COMMON DISORDERS THAT PRESENT WITH UNILATERAL VISUAL LOSS
1. Lumbar Puncture
○ For CSF analysis
2. Complete Blood Count
○ To document presence of systemic infection or hypersensitivity reactions
3. Urinalysis
○ To establish baseline values for further changes and therapeutic procedures
4. Chest X-ray
○ To document presence of respiratory tract infection
5. CRP
a. Used as an adjunct for presumptive determination of the etiologic
agent
6. ESR
a. Used as an adjunct to rule out other etiologic agents
7. Creatinine
a. To check for renal function as an aid in deciding the course of therapy
8. ANA Test
a. To exclude the presence of systemic autoimmune diseases
MRI RESULT
Interpretation
Axial T1, T2-weighted and FLAIR MRI sequences of the brain were performed with additional T2W sagittal and coronal sequences. Diffusion and susceptibility weighted images were also obtained.
There are multiple ill defined almost nodular lesions scattered throughout seen gray-white matter junction in both hemispheres including the parasagittal regions.
Despite the extent of the lesion there is no demonstrable significant mass effect.
There are no components of restricted diffusion or hemorrhage.
There is relative sparing of the deep nuclear and periventricular white matter regions. The brainstem and cerebellar regions are velar.
Images of the orbits reveal asymmetric appearance of the orbits with the right optic nerve larger than the left. The right optic nerve is further characterized by patchy T2 hyperintensity signals with
minimal surrounding fat stranding.
Screening T2 sagittal images of the whole spine fail to demonstrate any suspicious abnormal intramedullary hyperintensity signals.
Impression:
Multifocal ill defined lesions involving the gray-white matter junction in both hemispheres including parasagittal regions with additional findings consistent with right optic neuritis.
The pattern of involvement of the lesions without significant mass effect suggest a demyelinating etiology. Acute Disseminated Encephalomyelitis (ADEM) is the primary consideration.
No demonstrable intramedullary abnormalities within the spinal cord to suggest transverse myelitis.
MRI:
LABORATORY RESULTS
Lumbar Puncture Gross: Colorless, CLear
Cell count:
RBC: 18 cells/cu. mm.
WBC: 5 cells/cu. mm.
Differential count: Not done due to low WBC
count.
Urinalysis Unremarkable
- An anti-inflammatory and immunosuppresive agent, which is considered the mainstay of ADEM treatment. The presumed
autoimmune etiopathogenesis is taken into account for resolution of visual and neurologic deficits.
Supportive:
1. D5LR at 80cc/hr
3. Fall precaution
4. Strict handwashing at all times, limit visitors, and wear mask at all times upon
entering patient’s room
Course in the ward
Day 1 (July 17, 2019)
S: Patient has no subjective complaints apart from the fact that she cant see using
her right eye. Patient is not dizzy, no vomiting, able to maintain balance while
walking. No fever, no headache.
O: Seen patient awake, cooperative, afebrile, not in respiratory distress with the
following vital signs:
PR: 90bpm RR: 26cpm Temp: 36.2C
Skin: Good turgor & mobility, no rashes, no lesions.
HEENT: Normocephalic, anicteric sclera, no alar flaring.
C/L: Clear breath sounds, equal chest expansion, no adventitious breath sounds
CVS: Distinct heart sounds
Abdomen: no tenderness on light and deep palpation
GUT: (-)KPS, both sides.
Extremities: CRT<2 secs
CNS:
Cerebral: Coherent; oriented to time, place, and person
Cranial nerves:
CN 1: intact
CN 2, 3: (+) PLR EBRTL on left eye, (-) ln right eye; (+) RAPD on right eye; (-)
light perception on right eye
CN 3, 4, 6: full range EOM.
CN 5: (+) corneal reflex, intact facial sensations
CN 7: symmetrical facial expressions
CN 8: intact
CN 9, 10: able to swallow
CN 11: able to shrug shoulders equally against resistance
CN 12: tongue midline upon protrusion
Cerebellar: able to perform finger to nose test
Sensory: intact on both sides
Motor: 5/5 on all extremities
P: 1. Cranial MRI
2. Fall precaution
3. Steroids
Day 2 (July 18, 2019)
VIII: intact
Methylprednisolone 1 g/day
3. Monitor V/S
O: Seen patient asleep, afebrile, no alar flaring, not in respiratory distress w/the
following vital signs:
Cranial Nerves:
CN I: intact
CN II, III: (+)PLR EBRTL on L eye, (-) on R eye; (+) RAPD on R eye
CN VIII: intact
A: ADEM
P: - Continue medications
S: Patient complained of squeezing pain on her left lumbar area yesterday. Patient
screamed in pain then was given an analgesic. Patient had no episode of vomiting
but sometimes complained of nausea. Patient did not have a febrile episode. No
complaint of headache, no changes in sensorium. No other subjective complaints.
Day 4 (July 20, 2019)
O: Seen patient asleep, afebrile, no alar flaring, not in respiratory distress
CN:I: intact
II, III: (+)PLR EBRTL on L eye, (-) on R eye; (+) RAPD on R eye
VIII: intact
A: ADEM
P: - Continue medications
- Refer accordingly
Day 5 (July 21, 2019)
S: Patient has no subjective complaints. Patient is able to see light with her right
eye. Patient is afebrile for the past 24 hours. No vomiting, no dizziness, no
headache. Patient has adequate urine output and appetite is good. Patient walks
with assistance without dizziness.
C/L: equal chest expansion, (+) rhonchi on L lower lung field, (+) chest tightness
on R lung field, (+) adventitious sounds
Cerebellar: able to perform finger to nose test, walks assisted with no imbalance
Sensory-intact
Motor: 5/5 on all extremities
Day 5 (July 21, 2019)
A: Acute Disseminated Encephalomyelitis
P: Continuous medications:
O: seen patient awake; afebrile, coherent, not in respiratory distress with the
following vital signs:
Neck:(-) lymphadenopathies
CN I: intact
CN II, III: (+)PLR EBRTL on L eye, (-) on R eye; (+) light perception at right eye
O > seen patient asleep, afebrile, not in respiratory distress with the following vital
signs:
HEENT – anicteric sclerae, no nasolacrimal discharges, (-) alar flaring, tonsils not
inflamed
NECK – No lymphadenopathy
CN: I: intact
II, III: (+)PLR EBRTL on L eye, (-) on R eye; (+) light perception at right eye
VIII: intact
A – ADEM
O: Patient seen asleep, afebrile, not in respiratory distress with the following vital
signs:
I: intact
VIII: intact
Day 8 (July 24, 2019)
IX, X: able to swallow
> Oral prednisone 20 mg/tab 1 1⁄2 tablet after breakfast and dinner was started
> Advised mother about susceptibility of patient to diseases due to steroid therapy
> Patient is stable and may be discharged today
TREATMENT FOR ADEM
DISCUSSION ON IMPROVEMENT OF
VISION
PROGNOSIS