Module: Night Blindness

Case
Alden, 4 years & 6 month-old male child, Roman Catholic, daycare pupil, from Fuerte, Caoayan
Ilocos Sur was brought for consult at the OPD section of Ilocos Sur Provincial Hospital – Gabriela Silang
Informant: mother % reliability: 85%

Chief complaint: blurring of vision

History of Present Illness

5 months prior to consult (PTC), patient was noted to have frequent blinking associated excessive
tearing and frequent rubbing of his eyes. Mother thought it was due to excessive use of gadgets as Alden
spends almost 4-5 hours using alternately the personal computer, iPad and mobile phone for playing
children’s games & watching You Tube; she gave multivitamins (for “good vision”) that she heard from
her kumadre; no improvement was noticed.
2 months PTC, patient was enrolled as a daycare pupil in Brgy. Fuerte, Caoayn, Ilocos Sur; he was
very quiet in his class only to recite when his name is called; his teacher noticed that during class he
frequently rubs his eyes & usually avoids areas in the classroom with excessive exposure to sunlight. He
almost never consumes his baon (cupcakes/cookies & chocolate drink prepared by his mother); since the
school embarked on a feeding program project, Alden usually refuses to eat vegetables & fruits, prefers
fried chicken & meat only. Alden was forbidden to use gadgets at this time.
1 month PTC, one night while Alden & his siblings were playing board games, the older sister
noticed that he picks up the wrong color & identifies wrong letters of the alphabet; another time when
he runs to pee, he stumbles & hit his right knee on the edge of a chair; her sister noticed these symptoms
for almost 2 weeks and informed their mother; Alden was brought for consult to an optometrist, who
gave “eye vitamins” & prescribed glasses as Alden is said to be near-sighted but afforded temporary relief
of eye symptoms, thus was brought for consult.

Past Personal History

Unremarkable

Past Medical History

At 1 year of age, patient was admitted in a private hospital in Bantay, IS due to watery stools &
vomiting; diagnosis was acute gastroenteritis, discharge improved after 48 hours of hydration and giving
of probiotics.
At 2 years of age, patient was diagnosed to have Primary Koch’s infection, treated with Rifampicin,
INH + B6 and Pyrazinamide.
At 3 years of age, patient has a history of dog bite (pet owned by the neighbor, not vaccinated);
he was brought to GSGH animal bite center for the post-exposure rabies prophylaxis which he completed.
The dog died 3 months later after it was hit by a fast-moving car.
Denies previous surgical operations, trauma or accidents.

Feeding history
Eats diet for age, but fond of drinking sodas & eating chips & cookies; shines away from fruits,
vegetables & prefers fried foods most of the time.

Developmental history
Patient presently attends day care center schooling in their barangay, said to be apathetic in class;
can write full name legibly, knows names of parents, siblings, teacher & classmates, address; can dress
himself unaided, names 4-5 colors, counts up to 10, can draw a person with hands & clothes.

Immunization history
Patient received 1 BCG, 3 DPT, 3 OPV, 3 Hepatitis B vaccine, 1 measles & 1 MMR, all given by the
City Health office personnel, with no untoward reactions noted.

Family history
Father, 36 year-old OFW who works in UAE, smokes & drinks alcoholic beverage occasionally,
apparently healthy; Mother, 34 year-old college undergraduate, employed as clerk in a grocery store,
apparently healthy; patient is the youngest among 5 siblings, all siblings are apparently healthy.
Paternal grandmother died of CVA; maternal grandmother died of cavitary PTB.
Denies history of bronchial asthma, diabetes, blood & other malignancies.
Socio-economic history and Environmental history
The family lives in a well-lit, well-ventilated family-owned bungalow house in a crowded
environment, with 2 BR and 1 common CR; there are 5 family members living in the house, with 1 stay-
out 50 year-old house-help (a relative); the house is located near the barangay hall & basketball court and
small make-shift market stalls along the barangay road; no nearby factories or dump sites.
Water for drinking purposes is purchased from a water-refilling station; garbage is collected by
the health sanitary team every afternoon and the barangay is practicing waste-segregation procedures.
Family income comes from the renumeration of both parents.
ROS
(-) fever, body weakness, (+) decreased appetite, (-) altered sensorium
(-) headache, colds (-) diplopia, (+) blurring of vision
(-) cough, tachypnea, circumoral cyanosis
(-) chest pains, easy fatigability
(-) vomiting, abdominal pain (-) diarrhea, constipation
(-) dysuria, hematuria, edema
(-) palpitations, temperature intolerance
(-) hallucinations, tremors
(-) joint pain & swelling, limitation of motion, limping

Physical examination
Patient is conscious, coherent but somewhat “shy”
CR = 120/min, RR = 25/min, BP = 80/50 mmHg, Temp = 37 C/axilla
Wt = 14 kgs, Ht = 100 cms
Skin is warm to touch, good skin turgor, dry with some desquamation
Normocephalic, no head lumps, with good hair distribution, hair is coarse
Pale palpebral conjunctivae, anicteric sclerae, pupils ERLA, (+) ROR, cornea is hazy, (+) well
demarcated, superficial, dry, grayish, silvery foamy plaques lateral to the cornea, OD > OS
Patent EAC, (+) minimal cerumen, AU, well-visualized TM with no perforations &
erythema
Midline septum, (+) minimal purulent nasal discharge
Pinkish & moist buccal mucosa, dry tongue, no TP wall congestion & exudates, (+) dental
carries
No neck masses, no venous engorgement
Symmetrical chest expansion, no retractions, clear breath sounds, no wheezing
Adynamic precordium, tachycardic, regular rhythm, presence of hemic murmur
Abdomen is slightly globular, soft, no tenderness on all quadrants, no masses palpated, NABS
No costovertebral angle tenderness
Midline urethra with no discharges, bilaterally descended testes, SMR 1
Good sphincteric tone, empty rectal vault, no tenderness on all quadrants, no blood on examining
finger
No clubbing, full & equal pulses, capillary refill < 2 seconds

Neurologic examination
Oriented to 3 spheres
Pupils are 2-3 mm in size, ERTL
Can move the eyes upward, downward and sideways (intact EOM movements)
(+) blinks corneal stimulation
No facial paralysis
Midline uvula, (-) gag reflex, drooling saliva
No tongue deviation or fasciculations
Motor: 5/5 in all extremities
Sensory: 100% in all extremities
Intended Learning Outcomes
At the end of the module, students are able to:
I. Identify the parts and function of the human eye
II. Define basic terms & concepts of vision
1. Identify & define the symptoms (presented by the patient)
III. Outline & illustrate the visual pathway
IV. Point out pathologies of the visual pathway (relating to the patient)
1. Generate the differential diagnosis
V. Determine the signs and symptoms of the specific nutritional deficiency
VI. Illustrate how to assess nutritional deficiency
1. Visual assessment
a. Snellen's chart
b. opthalmoscopy
2. Assessing other signs & symptoms of nutritional deficiency aside from visual manifestations
a. Physical examination findings
3. Ancillary procedures to assess the nutritional deficiency
VII. Plan the treatment modalities of the specific nutritional deficiency & related nutritional deficiencies
VIII. Outline the preventive measures of the specific nutritional deficiency & related nutritional
deficiencies

Outcome-based Assessment

Teaching and Learning Activities

case-based discusssion
small group discussion and class presentation of outcome