MEDICAL DISCLAIMER
Medical Disclaimer: The cases presented
here are fictional patient cases. These
are referenced and created by Ninja Nerd
Inc and are meant for educational
purposes only. This is not meant to
diagnose or treat medical conditions.
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SUBJECTIVE
HPI:
❏ 30 year old female with no significant PMH presents to your Ninja
Neurology clinic as a consult from her primary care physician and
optometrist for decreased visual acuity. She states the vision
problems began a month ago and have been getting progressively
worse. She states that she cant read or see things as clearly as
she could before and says that she also has difficulty differing
colors. She states that the vision problem is mainly in her left
eye. Patient denies any history of myopia, hyperopia, doesn't wear
contacts or glasses, and denies any recent medication use.
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Physical exam
❏ VSS
❏ General
❏ Obese female who appears stated age in NAD
❏ Neuro
❏ Mental status: AAO x4, good attention to examiner, language
intact
❏ Cranial nerves:
❏ II: OD: 20/40 OS: 20/100, Visual fields decreased in left eye,
Pupils equal but RAPD in left eye
❏ III/IV/VI: Loss of adduction during tracking, nystagmus during
abduction, convergence normal, exotropia at rest
❏ Motor: 5/5 in UEs and 3/5 strength in LEs
❏ Sensory: decreased vibration and light touch sense on B/L LEs
❏ Tone: Hypertonia in LEs
❏ Reflexes: 3+ patellar reflexes B/L, no clonus
❏ Coordination: Intention tremor present
❏ Cardiovascular: RRR, Normal S1 and S2
❏ Pulmonary: CTAB
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She tells you something interesting
❏ She says when she gets a hot bath she
gets really weak, fatigued and her
vision gets even worse but then she
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goes back to normal later
❏ What’s this called?
❏ Uhthoff's phenomenon
let’s hear your DDX?
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What tests do you want to order?
The MRI
What is first line treatment?
❏ A. Plasmapheresis
❏ B. 10 mg of dexamethasone for 5 days
❏ C. 1 g IV methylprednisolone for 5 days
❏ D. Rituximab
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Steroids don’t work, What next?
❏ A. Plasmapheresis
❏ B. IVIG
❏ C. Continue steroids
❏ D. Glatiramer acetate
Patient refuses plasmapheresis, whats alternative?
❏ A. Rituximab
❏ B. IFN-beta
❏ C. IVIG
❏ D. ACTH injections
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Started on rituximab for prevention
❏ After being on rituximab for a year and having
recurrent flare ups requiring multiple bouts
of steroids, patient returns to clinic with
headache, confusion, severe lethargy and
vomiting.
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You order CT and see this?
❏ What’s this called?
❏ Hydrocephalus
What caused this hydrocephalus?
❏ Communicating or Obstructive?
❏ If communicating what could be the cause?
❏ Meningitis
❏ Intraventricular hemorrhage
❏ Subarachnoid hemorrhage
❏ Normal pressure hydrocephalus
What test should i order for meningitis?
❏ Lumbar puncture
❏ MRI AfraTafreeh.com
❏ CBC
❏ I have no idea
What the heck?
❏ Lumbar puncture CSF results come back
❏ Increased Protein
❏ Increased Lymphocytes
❏ India ink smear positive
❏ Latex agglutination assay positive
❏ What type of meningitis?
❏ Cryptococcal meningitis
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Why did this person develop cryptococcal meningitis?
❏ Immunosuppressed state from high dose steroids
and rituximab
How do i treat cryptococcal meningitis?
❏ Relieve hydrocephalus with what?
❏ EVD
❏ Kill yeast with what Antifungal regimen?
❏ Amphotericin
❏ Flucytosine
❏ Fluconazole
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Q&A
