History of Presenting Illness in Neuro-Ophthalmology

Summary: • The HPI is taught to medical students through the mnemonic OLDCARTS: o This method gathers information regarding the onset, location, duration, characteristics, associated symptoms, radiation, timing, severity of symptoms (from 1 to 10), and aggravating and relieving symptoms of the chief complaint. • As a medical student it is good to have a consistent framework when approaching the history of present illness; however, OLDCARTS can be modified to be more effective o We prefer to hear about every doctor and every visit from the time that the patient was last well to the current day o There is something before the manifestation of the chief complaint that is important in establishing the differential diagnosis; o; We want to start the history of present illness from when the patient was last well. • Case 1: 20-year-old white female presenting with acute unilateral loss of vision, pain with eye movement, RAPD, and a normal fundus. o We know this case is headed towards optic neuritis but if we start the case from when the patient was last well, we get a different story. • Case 2: 20-year-old female presented 4 weeks prior with new onset of hiccups, nausea and vomiting, had symptomatic sleep attacks consistent with narcolepsy, has vision loss, pain with eye movement, RAPD, and a normal fundus o Now the differential moves from optic neuritis towards neuromyelitis optica (NMO) o NMO patients often have disease before the vision loss o Area postrema involvement and other aquaporin forage areas cause non-demyelinating like symptoms and it is difficult to suspect a demyelinating disease without starting from when the patient was last well. • Case 3: 80-year-old white female presenting with acute, unilateral loss of vision to no light perception. She has a relevant afferent pupillary defect and a normal fundus. o This is retrobulbar optic neuropathy not form optic neuritis but from ischemic optic neuropathy -This is called posterior ischemic optic neuropathy because we don't see the disc edema o The symptoms will have started before the vision problem. Examples: -jaw pain when they chew their food -scalp tenderness, headache -polymyalgia rheumatica