NOPE.. She is not a malingerer nor a pretender…her complaints are genuine, your incompetency and ignorance almost cost her LIFE, you have missed her tumour…the symptoms and signs were so clear..

I have not been writing for a while… a very long while… usual excuse…being busy, and perhaps pretending to be busy so I could escape to another world..but one incident which I encountered last weekend forced me to pen down my thoughts again.

Well, to start off, it is not for me to downgrade or condemn any of my fellow colleagues… every speech I utter, every knowledge I share is just a call for everyone to reflect on themselves and of course a lesson to be learnt no matter at which level we are in our society. Be it a fresh graduate who has just started working as an Optometrist, or someone who has been working at the government hospitals for more than 10 years, private practice Optometrist who wholly owned his business or even a professor at the university… we will not learn anything till we make mistakes, we will not learn anything until we are being criticized, we will stay complacent with whatever we have…because life is always so forgiving…being a professional we rarely get negative comments, we are always being looked upon to.. in short..the public out there put the whole trust on us.

I met this girl who walks into my clinic by appointment, 11 years, a typical Malaysian schoolgirl with serious passion in comics, animae movies, obsess with her handphone.. accompanied by parents for an eye checkup. I initially thought it was going to be a normal routine eye test and all till her mum told me that she is seeing red as white, and only report of seeing white, grey and black… To be honest, I have never encounter an acquired colour defect as such. She was wearing a red tudung and a red blouse on that day, when I approached her by asking what colour is your ‘tudung’…she answered confidently …white, same answer for her blouse…” white”.. she said. I pointed at the white walls in the refraction room and repeated the same question and she confidently took a glance and said “white”.  I paused and starred at her disbelieved, silently I tried to read and translate her body language...at times I paused and tried to divert her mind to something else throughout the whole examination just to get to the true her.

She was previously seen by an optometrist in a government hospital who has regarded her as malingerer and she was then suggested to see a psychiatrist. The optometrist was adamant of her judgement that she refused to see this girl each time she was brought to the hospital for follow ups, and according to her mum, she never get to the stage of seeing an ophthalmologist because the optometrist and a medical officer confidently thought she has normal vision and has no colour vision problem and that she was just putting up a show to attract her mum’s attention (mum showed me the referral letter). She was diagnosed as having “Child Behaviour Disorder”. Mum revealed that her teachers at school thinks she is slow and trying to create drama, one teacher even threw a red pen at her when she said she could not recognize the red colour. Whenever a teacher writes using a red marker on a white blackboard, she would not able to see anything (because she sees red as white). For 3 years, she has endured all these difficulties and no one believed her complaints except for her parents.

                    

                    PICTURE IS  FOR DISPLAY PURPOSE ONLY - NOT ACTUAL PATIENT.

I noticed that she was rather sensitive to sounds as will cover her right ear whenever the auto cleaning machine vibrates (to clean spectacles) in the other room and you can hear her sigh and complaining about the disturbing sound the machine gave out. The mum add on that she will be very disturbed by the sound of heavy vehicles on the road too. Towards the end of the examination (45 minutes) she was complaining of stiffness on the right side of her body (her arms and legs). Mum also reported that she has a serious peptic ulcer condition.

Visual acuity test was simple as she has low myopia and achieved 6/7.5 for each eye though she complained not being able to see the whole line all at once. Visual acuity for near was normal but she found its difficult to read, she brings the material closeup to her face and struggled to read smoothly. She reported that it was hard for her to read as the words looks doubly and cramped all together. Further assessment found that she has acquired intermittent squint on her left (noticed 3 years ago) and that makes it difficult for her to converge her eyes when reading at near and she is unable to fixate an object even at 16cms from her eyes. I could see she tried and obediently followed my instructions throughout the assessment. EOM test showed all eye muscles are functioning well except the adduction problem of left eye is clearly limited. Acquired squint is uncommon, I only usually see it in high intracranial pressure cases and trauma.

Next, I proceeded with Ishihara Plates to test her colour defects, true enough she only passed the first plate (the malingerer proof plate) and failed the rest. I could see her effort trying so hard to see but finally she just shook her head with disappointment with each page I flipped in front of her eyes.

Mum then said..oh yes Doctor, I forgot to tell you that she has tunnel vision as well.. now my brain is all confused with the symptoms she is experiencing and the signs which I discovered plus previous report made by the optometrist and medical doctor in the government hospital. To be honest everything is perplexing now. It gets more complicated with the more numbers of assessment I am doing and planning to do… somehow, I felt it was leading me to know where now.

Okay, not to give up just yet…. I silently told myself lets get on doing confrontational Visual field test as I do not have a high-tech instrument in my practice. Confrontational visual field confirmed the findings. Yes she has limited visual field. Only 30 degrees on each eye. How could that be? Well she doesn’t appear to be knocking her sides while walking. She is active, and a typical 11-year girl would not have a cat walk style of walking…so that looks rather alright to me. But here I conclude this is not a typical tunnel vision which was described by mum and in the referral letter. This is actually blindness of the temporal half of each eye. Binggo! This is the opener to what was bothering me at the back of my head from start. Differential diagnosis at this point was…tumour in the brain, head concussion due to trauma, meningitis (nope.. she was not ill before this..but ..yeah who knows..), early onset of multiple sclerosis (??), brain stroke or… maybe I am just walking on the wrong pathway all together and that she was malingering , pretending, seeking for attention (her being the only child), But the symptoms and signs were like placing itself nicely in a complex jigsaw puzzle.

Taking in a deep breath I asked her mum again, does she ever complaint of throbbing headache at night which the pain awakens her, and…sigh..mum said yes..most of the nights…my examination stops there.

I have not given her any optical treatment as I only wish to refer her to a neurologist straight away and to order a CT Scan or MRI. My diagnosis ..Neurological Vision Impairment (for now) till the CT scan/MRI could prove something else.

Lesson to be learnt… this story I have shared is not to show that I have successfully come to a right diagnosis or not, but it is to somehow made us all aware that we may not be superb in recognizing all diseases even though we are professionals in this field, but sometimes it is still worthwhile to listen to complaints, symptoms with deeper care…doing history taking is just not for recording purposes and if we do face a perplexing situation, step down to refer for a second opinion or perhaps set for another opinion so we will have time to do some research / study in depth in accordance to patient’s symptoms and signs. It’s okay guys…to apologize and ask patient to seek for a second opinion rather then dismissing them as malingerer, pretender and worst still diagnosing them with a condition where we are not the expert. Diagnosing a child to have behavioral problem should be the decision of a psychiatrist not a medical doctor.

There are times when we get patients who are malinger or drama icons who wished to test our patience … we need to know and have the skill of distinguishing a genuine problem and “a made-up bed time story”. Nevertheless if we do not have the skills of this, just give a good ear to listen to patients complaints and if we come to the walls with our petty knowledge, just kindly refer them and not cleverly pass an unsound judgement as it may cost one’s life without you even knowing it..

Do good to a future and not damage it with our ego...God bless..

Dr Haliza

23-04-2019