Q1: 25 - year old driver, involved in car accident , present to hospital with bilateral lower limb

fractures,1 day later he reports decreased vision in right eye, vision counting finger in right eye,
20/20 in left eye. You found bruising on forehead
What is your Differential Diagnosis, and how to manage?
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Q2: 38 year- old woman, referred to you with right cataract, on examination present with
posterior subcapsular cataract. Mild anterior chamber reaction, Aquous flare scattered keratic
peripcepitates all over the endothelium.
a) What is the Diagnosis?
b) What other clinical findings?
c) How to assess and manage?
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Q3: 65 year- old man with history of alcohol abuse, present with decreased vision, visual acuity
6/18 in both sides, with clear media, fundus examination show bilateral optic disc pallor with no
other abnormalities
How to assess and manage?
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Q4: 25 year- old man come to visit his friend in the ward, when he suddenly found unconscious
a) How to initially assess?
While you assess the patient, the nurse rush to you informing that she found the morphine
stock window is broken and one ampule is not found.
b) What signs suggesting morphine overdose?
c) What is the treatment of morphine overdose?
d) What are other possible causes of this patient unconsciousness?
e) What are complications of Intravenous drug use that should be considered during surgery?

A 25 year old male driver has got a road traffic accident.

He has been admitted in the orthopedic ward for fractures in the lower limbs.
On examination there is bruises on the forehead.
The day after he notice reduction in the vision in the right side, visual acuity testing showed CF vision in
the right eye and 6/6 in the left eye.

What are your differential diagnoses and how do you manage the patient?

A copy of the answer with underlying the important

points
A 25 year old male driver has got a road traffic accident.
He has been admitted in the orthopedic ward for fractures in the
lower limbs.
On examination there is bruises on the forehead.
The day after he notice reduction in the vision in the right side,
visual acuity testing showed CF vision in the right eye and 6/6 in
the left eye.
What are your differential diagnoses and how do you manage the
patient?

Introduction
The impression I get on reading the question that the clinical picture suggests a 25 year old male
had a travel accident and he is complaining of vision lost (the measured visual acuity in his right
eye Counting fingers and in the left eye is 6/6) in his right eye a day after he was admitted to
the orthopedics ward and there was bruising in his forehead

History
-I would ask the patient if there is any direct trauma to the eye brow
-I would ask the patient if the trauma in the forehead by sharp or blunt instrument

Examinations
-I would check the pupillary reaction to rule out relative pupillary defect
-I would do slit examination if possible to check the clarity and intigrity of the cornea, crystalline
lens and to rule out the presence of hyphema or iridodialysis
-I would check the funds if possible to rule out optic avulsion, traumatic optic neuritis, vitreous
hemorrhage, commotio retinae, the patency of the retinal arteries or retinal detachment
-I would measure the intra ocular pressure

Differential Diagnosis
-Optic disc avulsion
-Traumatic Optic nerve neuropathy
-Vitreous hemorrhage,
-Commotio retinae
-Retinal detachment
-Fat embolism causing retinal artery occlusion

Investigations
-I would perform B-scan in a case of opaque media to rule out retinal detachment

Final Diagnosis
Hyphema

Management
-I would ask the patient not to move his head and to hold his head in the position of 45 degree

-I would prescribe topical steroids such as prednisolone acetate q2h and topical cycloplegics
agents such as cyclopan 0.5 % b.i.d.
-I would prescribe ocular anti hypertensive eye drops such as mixture of Timolol and Drozamid
b.i.d. in a case of elevated intra ocular pressure.
-In a case of high intra ocular pressure more than 60 I would advice the patient for anteroir
chamber wash after lowering the intra ocular pressure by using mannitol i.v.
- In a case of high intra ocular pressure more than 35 for 3 days, non clearing blood in the
anterior chamber for more than a week or the boold starts to stain the cornea I would advice
the patient for anteroir chamber wash

Conclusion
I am sure I will find a happy patient with one week and I would follow up the patient for the 1st 35 days as recurrent bleeding of the Anterior chamber may occur and then I will follow up the
patient for at least two weeks so I can examine the retina for any high risk retinal tears or
chorodial rupture

38 year old woman, referred to you with right cataract, on examination present with posterior
subcapsular cataract. Mild anterior chamber reaction, Aquous flare scattered keratic
peripcepitates all over the endothelium.
a) What is the Diagnosis?
b) What other clinical findings?
c) How to assess and manage?

A copy of the answer with underlying the important

points
38 year- old woman, referred to you with right cataract, on examination present with posterior
subcapsular cataract. Mild anterior chamber reaction, Aquous flare scattered keratic
peripcepitates all over the endothelium.
a) What is the Diagnosis?
b) What other clinical findings?
c) How to assess and manage?

Introduction
The impression I get on reading the question that the clinical picture suggests a 38 year old
female has been referred for cataract surgery and in her exam there is posterior sub capsular
cataract with mild flare and cells in his anterior chamber

History
-I would ask the patient when the reduction of vision started
-I would ask the patient when she is using any topical or systemic steroids or other medication
-I would ask the patient for any history of ocular trauma
-I would ask the patient if he suffered from any systemic illness

Examinations
-I would check the pupillary reaction to rule out relative pupillary defect
-I would do slit examination if possible to inspect of the cornea, changes in the iris and crystalline
lens
-I would check the funds for any signs of inflammation in the vitreous, choroid or retina to rule out
vitrities, choroiretinities, retinochorodities or vasculitis

-I would do gonioscopy to rule out any signs of twig like vessels or anterior synchia, mass or
atrophy in the iris
-I would measure the intra ocular pressure

Differential Diagnosis
-Toxoplasmosis
-Iris trauma
-Waardenburg syndrome
-Idiopathic congenital

Investigations
-Consult with rheumatologist
-Blood testing for IgG and IgM for toxoplasmosis
-Keratometry readings and A-scan using the SRK/T formula to calculate the intra ocular lens of
-B-scan to rule out retinal detachments or other pathologies in a case of funds can't be seen

Final Diagnosis
Fuchs uveitis syndrome

Management
-I would put the patient in a topical steroids course prior to the cataract surgery until I have a
clear anterior chamber (no cells nor flare) for 6 months
-I would do a phacoemulsification of the cataract lens and implant a foldable acrylic
hydrophobic intraocular lens
-I would continue to use topical steroids after the operation with a systemic steroids cover 3 days
before the operation and a two weeks after

Conclusion
I am sure that I will find a quite happy patient as such cataract in Fuchs uveitis syndrome usually
have a good prognosis but patient should understand that following up is essential as
inflammatory activity in the anterior chamber may recur

65 year- old man with history of alcohol abuse, present with decreased vision, visual acuity 6/18 in both sides, with
clear media, fundus examination show bilateral optic disc pallor with no other abnormalities
How to assess and manage?
A copy of the answer with underlying the important points
65 year- old man with history of alcohol abuse, present with decreased vision, visual acuity 6/18 in both sides, with
clear media, fundus examination show bilateral optic disc pallor with no other abnormalities
How to assess and manage?
Introduction
The impression I get on reading the question that the clinical picture suggests a 65 year old male
with the history of alcohol abuse presented with bilateral decreased vision 6/18 with clear media
and bilateral optic disc palor
History
-I would ask the patient if he is a smoker
-I would ask the patient when the reduction of vision started
-I would ask the patient for how many years he is drinking and about the quantitate of
consumption
-I would ask the patient if he suffered from systemic illness after the alcohol abuse
-I would ask the patient if he by chance drank a methyl alcohol
Examinations
-I would check the pupillary reaction to rule out relative pupillary defect
-I would do slit examination if possible to check the integrity of the cornea, and crystalline lens
-I would check the funds to assess the pale optic nerve and the integrity of the macula
-I would measure the intra ocular pressure
Differential Diagnosis
--

Investigations
-Consult with internist
-Blood testing for vitamin B12 levels

Final Diagnosis
Nutritional Optic Neuropathy due to chronic consumption of ethyl alcohol

Management
-I would ask the patient to stop the consumption of alcohol and to stop smoking if he is a smoker
-A well-balanced diet with plenty of protein and green leafy vegetables, vitamin
supplementation (thiamine, vitamin B12, folic acid, multivitamins).
-I would prescribe Vitamin B complex (B1 - B6 - B12) t.i.d.
Conclusion
I will explain to the patient the importance of stopping the consumption of alcohol and that the
visual prognosis is guarded due to the moderate visual reduction and the optic nerve

25 year- old man come to visit his friend in the ward, when he suddenly found unconscious
a) How to initially assess?
While you assess the patient, the nurse rush to you informing that she found the morphine
stock window is broken and one ampule is not found.
b) What signs suggesting morphine overdose?
c) What is the treatment of morphine overdose?
d) What are other possible causes of this patient unconsciousness?

A copy of the answer with underlying the important

points
25 year- old man come to visit his friend in the ward, when he suddenly found unconscious
a) How to initially assess?
While you assess the patient, the nurse rush to you informing that she found the morphine
stock window is broken and one ampule is not found.
b) What signs suggesting morphine overdose?
c) What is the treatment of morphine overdose?
d) What are other possible causes of this patient unconsciousness?

Introduction
The impression I get on reading the question that the clinical picture suggests a 25 year old male
is suddenly found unconscious because of suspect of morphine overdose

a) How to initially assess?

- I would ask his friend if the patient is drug addicted or was an addict
- I would ask his friend if the patient suffered from any psychological illness
-I would check the pupillary reaction to rule out pinpoint pupil
-I would check the pulse which may be weak and I will measure the blood pressure which may
be low.
-I would check the nervous system status to see if this unconsciousness is coma, or drowsiness
-I would check his respiratory status as I will search for any signs of apnea, shallow, or difficulty in
breathing
-I would check the patients skin as I may find bluish finger nail and lips

b) What signs suggesting morphine overdose?

-Eye: Pinpoint pupil

-Cardio Vascular: Low blood pressure and weal pulse
-Neurological: unconsciousness, coma, or drowsiness
-Respiratory: Apnea, Shallow or difficulty in Breathing
- Skin: bluish finger nail and lips

c) What is the treatment of morphine overdose?

-Mouth to mouth breathing in case of apnea
-Charcoal, laxative and fluids Intra Venous
-Naloxone as it may reverse the effect of the poison

d) What are other possible causes of this patient unconsciousness?

Head trauma as he may injured his head when he broke the window