Medical Neuroanatomy

Case Workbook

Contents

Case Study 1.1

Case Study 2.1

Case Study 2.2

Case Study 2.3

Case Study 2.4

Case Study 3.1

Case Study 3.2

Case Study 4.1

Case Study 4.2

Case Study 5.1

Case Study 5.2

Case Study 5.3

Case Study 6.1

Case Study 6.2

Case Study 7.1

Case Study 7.2

Case Study 7.3

Case Study 7.4

Case Study 8.1

Case Study 8.2

Case Study 9.2.

Case Study 9.3

Case Study 10.1

Case Study 10.2

Case Study 10.3

Case Study 10.4

 

 

 

 

 

 

 

 

 

 

Prepared by:

F.H. Willard, Ph.D.

Department of Anatomy

And

J.E. Carreiro, D.O.

Department of Osteopathic Manipulative Medicine

 

 

CASE STUDY 1.1

 

A 74-year-old retired lawyer was brought into a small community clinic in northern Maine complaining of a pain on the right side of his head and weakness on the left side of his body.

He had had mild hypertension for several years but was otherwise in excellent health. He had been in Maine on a hunting trip for the previous 3 days. On the day of admission he had been walking back to camp in a heavy snowfall when he suddenly developed pain behind the right ear, along with weakness of the left side of his body and dysarthria. He was brought immediately to the clinic, where he was examined by a physician's assistant. He was observed to be afebrile, to have a pulse rate of 88 beats per minute, regular breathing at a rate of 16 respirations per minute and blood pressure of 200/112 mmHg. He was awake, orientated, and followed commands. He was dysarthric and complained of a steady, moderately severe pain above and behind the right ear. His head and eyes deviated moderately to the right, and there was a left homonymous hemianopsia.

The patient denied any recent history of trauma, headaches, or dizzy periods. He admitted to consuming one to two bottles of beer each evening on the hunting trip but denied consistent use of alcohol in his daily life. He also denied the use of any illicit drugs and was not taking any prescription medications.

He was able to deviate his eyes just past the midline to the left, volitionally; however, with the doll's head manoeuvre, his eyes could be directed into the left visual hemisphere. The pupils were unequal, the right being 2 mm and the left, 3 mm; both reacted to light. Sensation was reduced in the left side of the face and cornea. There was a moderately severe, flaccid left hemiparesis interrupted intermittently by clonic movements of the leg and tonic flexor movements of the left arm. Stretch reflexes on the left side were reduced, but the plantar response was extensor.

Within an hour of admission, the patient was having periodic decorticate posturing on the left side. The right plantar response had become extensor. He gradually lost consciousness; within 4 hours of admission he was unresponsive except to noxious stimuli. At first, painful stimuli produced extensor responses on the left but decorticate responses on the right; however, this pattern finally matured into bilateral extensor posturing, slightly more pronounced on the left than on the right. By this time, the right pupil had dilated and fixed in an oval shape, being 7 mm vertically and 3 mm horizontally. Minimal oculomotor responses could be elicited to cold caloric stimulation, and the patient was hyperventilating. Blood pressure had risen to 235/150 mmHg.

One hour after entering the clinic, preparations were begun for emergency transfer to Bangor, Maine, the closest major medical centre, however, because of the snowstorm, air travel was impossible and ground transportation was slow. Treatment with mannitol was started, and during the next hour the patient's condition stabilized, except that the right pupil became round and regained a minimal reaction to light. En route to Bangor, the patient's blood pressure dropped to 160/60 mmHg, he began to vomit, and his temperature rose to 39.6 degrees centigrade. He began to sweat profusely, and within 6 hours of initial presemnation at the clinic, the decerebrate responses had become less intense, the pupils were fixed, slightly irregular at 3 to 4 mm in diameter, and unequal, oculocephaic responses were absent, and respiration was quiet and shallow. Within 8 hours of admission to the clinic (2 hours into the trip to Bangor), respiration was ataxic, the pupils remained slightly unequal, with no oculovestibular responses; and the patient was diffusely flaccid but had bilateral extensor plantar responses and mild flexor response in the legs to noxious stimulation of the soles of hte feet. He died 30 minutes later while still en route.

 

 

 

 

QUESTIONS

  1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
  2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
  3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
  4. Are any changes in sensory functions detectable?
  5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
  6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
  7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
  8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
  9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?

 

 

 

Case Study 2-1

This 68-year-old, left-handed, retired businessman was referred for evaluation of progressive weakness and atrophy of his extremity musculature.

History of Chief Complaint:

He has enjoyed good health up until 9 months prior to the current presentation. At this time the patient had noticed an abnormal weakness in his arms; over the 9-month period since, the weakness has become progressively worse, spreading to his legs. Three months prior to his current evaluation, his wife noted a change in his speech; in addition, he began to have difficulty swallowing. Recently he has experienced difficulty dressing and eating. At present, he no longer feels capable of safely driving the family car.

Family History

He is married, his wife is alive and they have two children, both of whom are no longer residing in the house.

Medical History

Tonsillectomy at age 12 and a hernia repair operation at age 45.

General Physical Examination

He is an awake, oriented, well-hydrated man who appears slightly older than his stated age. Significant loss of muscle mass was noticeable in the shoulders, arms, and legs. Muscle loss was most prominent in the thenar eminence of both hands. His heart rate and blood pressure were within normal ranges. Peripheral pulses were intact at the wrists and ankles. Respirations were 16 per minute. Abdomen was soft with no masses; normal bowel sounds were present. Rectal sphincter tone was palpable. No lymphadenopathy was noted. Skin was supple with no bruising.

Neurologic Examination

Mental Status. He was awake and oriented for time and place. His fund of knowledge and memory were appropriate for his age. He could recite a list of the last five presidents and accurately, follow four-step commands. His speech was slow and his pronunciation of words was slurred; however, speech patterns and content were meaningful. He gave an accurate history.

Cranial Nerves. His visual fields were full and he had a complete range of eve movements. Pupillary reflexes were intact to both direct and consensual light. Facial expressions were intact and bilaterally symmetrical; the corneal, jaw-jerk, and gag reflexes were present but sluggish. His tongue protruded on the midline, but was weak; fasciculations were present on the surface of the tongue. Response to pinprick was intact throughout his face.

Motor Systems. Strength was 3/5 at the shoulder and elbow and 2/5 at the wrist bilaterally; grip strength was 2/5. Strength was 3/5 at the hip, knee and ankle bilaterally. Deep tendon reflexes were elevated at 3/4 around the knees and 4/4 around the ankles. Conversely, deep tendon reflexes were depressed at the elbows and wrists (1/4). Significant atrophy was present bilaterally in the forearms and arms and most prominent in the thenar eminencies. Widespread fasciculations were noted at rest in all four extremities. The patient was able to rise from a chair and walk only a short, distance unassisted. A fine tremor was present in the upper extremities when they were held in the extended and pronated position. The tremor diminished when his arms were lowered into a resting position. He noted that the tremor became worse when he is feeling stressed and when he drinks 2-3 cups of coffee. Finger-to-nose and heel-to-shin testing was normal in all extremities. No pronator drift was observed. His bowel and bladder functions were intact.

Sensory Exam. Discriminative touch, vibratory sense, proprioception, and pain and temperature sensation were intact throughout his body.

Follow-up

Re-examination in six months revealed strength at the shoulder and elbow to be 2/5 and at the wrist 1/5. Grip strength was also 1/5. Strength at the hip was 3/5 and at the knee and ankle 2/5. Deep tendon reflexes remained trace to 1/5 in the upper extremity and were 2/5 at the knee and 1/5 at the ankle. He lacked any response to gag and complained of frequent choking spells when swallowing.

 

QUESTIONS

  1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
  2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
  3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
  4. Are any changes in sensory functions detectable?
  5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
  6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
  7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
  8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
  9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?

 

 

Case Study 2-2

Chief Complaint

A 27-year-old, right-handed machinist was brought by ambulance into the emergency room after suffering a knife wound in the back. He was conscious but somewhat intoxicated. A penetrating wound was present on his back, slightly off the midline and opposite the superior border of the right scapula.

History of Chief Complaint

He had been involved in an altercation in a local tavern. The knife wound occurred at 1:35 in the morning after an evening spent watching a national sports event and consuming alcoholic beverages.

Family History

He is single and lives in an apartment. He has two brothers and a sister; his mother and father are divorced.

Physical Examination

This is a stable male patient with a penetrating wound on his right back that entered the spinal column. Heart rate is 70, blood pressure is 145/90 and respirations are 18; peripheral pulses were intact at the wrists and ankles. The wound is located on the right side and approximately one inch above and one inch medial to the medial end of the spine of the scapula. The patient is an awake, intoxicated male. He is muscular, well nourished, well hydrated, and appears his stated age.

Neurologic Examination

Mental Status. He was awake but somewhat intoxicated. Speech was slurred and rambling; however, no word substitution or word confusion was present. Memory and knowledge could not be tested adequately because of his level of intoxication.

Cranial Nerves. A full range of eye movements was present. Hearing was normal bilaterally. Pupillary, gag, and corneal reflexes were intact; facial movements were full; uvula and tongue were midline.

Motor Systems: There is a proximal-to-distal, graded diminution of strength in the upper extremity on the right. Power was 4/5 for shoulder elevation, 3/5 for the forearm flexors and extensors, 1/5 for the flexors and extensors of the wrist and in the fingers. Grip strength was abolished completely. All strength was absent in the right lower extremity. Deep tendon reflexes were depressed about the elbow (1/4) and absent about the wrist and in the digits as well as throughout the lower extremity (4/4).

Sensory Exam. Complete loss of the sensation for pinprick and temperature was found over the left trunk below C8 and in the left lower extremity. Loss of discriminative touch and vibratory sense was found over the right half of the body below and including C8.

Follow-up

Two weeks later a neurologic examination revealed no change in the distribution of sensory loss, and strength remained diminished in the forearm, hand, and complete lower extremity on the right. However, the following changes were seen: Deep tendon reflexes were elevated at the wrist, finger, knee, and ankle on the right side. A Babinski sign could be elicited from the right foot.

 

 

 

 

 

 

 

 

QUESTIONS

  1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
  2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
  3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
  4. Are any changes in sensory functions detectable?
  5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
  6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
  7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
  8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
  9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?

 

Case Study 2-3

A 36-year-old man is referred for evaluation by his family physician. He is presenting with a progressing weakness and sensory loss in the upper and lower extremities and with the recent onset of dyspnea.

History of the Chief Complaint

He first noticed the weakness and loss of sensation to temperature in the upper extremities 12 months previously; the onset of weakness in the lower extremities has occurred in the past 4 months. He has noticed the onset of shortness of breath in the last month.

Medical History

He has enjoyed good health until 18 months ago when he suffered a road traffic accident. While stopped at an intersection he was struck from behind and received a whiplash injury. He wore a cervical collar for two months following the accident and still experiences neck pain and paraspinal muscle spasms for which he is taking medication. He has no history of blood transfusions, denies IV drug abuse, and has not been out of the country except for an occasional trip to Canada. He denies any recent history of noticeable viral or bacterial infections. He denies any history of respiratory tract illnesses.

Medications

Voltarinâ to relieve the neck pain and Flexerilâ for the paraspinal muscle spasms.

Social History

He is a faculty member at a small liberal arts college, has never married, and lives alone. He does not smoke or consume alcohol and denies any sexual activity

Family History

His mother and father are still alive and in good health, he has no siblings.

General Physical Examination

This is an awake, oriented male, appearing older than his stated age and with noticeable muscle wasting in the upper extremities. His heart rate is 90, blood pressure is 127/85, temperature is 98.7oF, and respirations are 19. During respiratory movements his sternum moves anteriorly, but little lateral motion occurs along the subcostal margins. On inhalation, his sternocleidomastoid muscle becomes prominent. Respiratory movements are rapid but of short duration. His skin is moist and supple. His chest is clear to auscultation and abdomen was soft to palpation with no tenderness. No lymphadenopathy is detected in the axilla or groin area.

Neurologic Examination

Mental Status. He is awake, oriented for person, place and time, and has an appropriate memory and knowledge base. Speech is clear and meaningful. He can follow three and four-step commands, but is hampered by his weakness.

Cranial Nerves. A full range of eye movements is present; visual acuity was 30/20 in the right eye and 40/20 in the left eve without glasses. Pupillary reflexes are present to direct and consensual light. Hearing is intact to finger rub at both ears. Gag and corneal reflexes are intact and facial movements are full. The uvula is symmetric and the tongue protruded on the midline.

Motor Systems. Strength in the upper right extremity is 4/5 at the deltoid, 3/5 at the triceps, 3/5 at the biceps, 2/5 and at the brachioradialis; grip strength is 3/5. In the left upper extremity strength is 4/5 at the deltoid, 3/5 at the triceps, 2/5 at the biceps, 2/5 and at the brachioradialis; grip strength is 4/5. The lower extremity strength exam finds the quadracepts at 3/5, the gastrocs at 3+/5 and anterior tibialis at 4/5 on the right. On the left, the quadraceps is 2/5, the gastrocs is 3/5 and anterior tibialis is 4/5. Both upper extremities have diminished deep tendon reflexes at the elbow, and wrist, muscular fasciculations, and atrophy is present bilaterally. Both lower extremities had elevated deep tendon reflexes and the plantar reflex is extensor bilaterally.

Sensory Exam. He lacked sensation to temperature and pinprick in a cape-like distribution over the chest and shoulders extending throughout the upper extremities to the fingertips. Vibratory sense, discriminative touch, and proprioception were intact throughout his chest and upper extremities. Normal sensation was found elsewhere over the body.

 

QUESTIONS

  1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
  2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
  3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
  4. Are any changes in sensory functions detectable?
  5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
  6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
  7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
  8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
  9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?

 

 

Case Study 2-4

 

An 82-year-old, right-handed man with a long history of illness, was brought to the emergency room by his family; he was in acute distress with back pain and unable to walk.

History of Complaint

Patient experienced severe back pain radiating into both legs that remitted promptly when lying down. The next day he experienced similar transient pain in the back and the legs. Later that day, while experiencing an episode of severe back pain, his legs became paralyzed and he was rushed to the hospital.

Medical History

The patient had a previous history of transurethral prostatectomy and bilateral orchiectomv for carcinoma of the prostate, left hemicolectomv for adenocarcinoma of the rectum, and arteriosclerotic heart disease and congestive heart failure.

General Physical Examination

He was awake, cooperative, and afebrile and appeared older than his stated age. Funduscopic examination revealed bilateral ocular opacities obscuring visualization of the fundi. External auditory canals were patent. No cervical lymphadenopathy was detected. Blood pressure was 160/90 mmHg, pulse rate was 48 beats per minute with occasional premature beats. There was a grade 2 blowing apical systolic murmur. Bilateral basilar crackles were present in the lungs on inspiration and bilateral jugular venous distention was demonstrable in the neck. Peripheral pulses were intact and equal at the wrists and ankles. Pitting pretibial edema was present. A colastomy stoma was present in the lower left quadrant of the abdomen. Otherwise the abdomen was soft to palpation with normal bowel sounds and no aortic bruits.

Neurologic Examination

Mental Status. He was alert and oriented to person, place and time; memory and affect were appropriate for his age. Speech was clear and meaningful. He was a good historian.

Cranial Nerves. His visual fields were intact and eve movements were full; hearing, to finger rub, was diminished bilaterally. His pupillary, corneal, and gag reflexes were intact: facial expressions were appropriate; uvula elevated symmetrically and tongue protruded on the midline. When asked, he could elevate his shoulders symmetrically with appropriate strength.

Motor Systems. His strength and muscle tone were absent in both lower extremities and deep tendon reflexes were absent at the knee and ankle. His strength and reflexes in the upper extremities were appropriate for his age. His urinary bladder was neurogenic, however, this had been present since his last surgery.

Sensory Exam. There was a well-defined sensory level at T10, below which he had lost sensation to pinprick and temperature. Touch, vibratory, and position sense were intact throughout his body and face.

Follow-up

He was treated with steroids and supportive measures without improvement. Five weeks after the onset of paraplegia he died from a sudden cardiorespiratory arrest.

 

 

QUESTIONS

  1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
  2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
  3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
  4. Are any changes in sensory functions detectable?
  5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
  6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
  7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
  8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
  9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?

 

 

Case Study 3-1

A 59-year-old man with headaches, double vision, dizziness, and ataxia

Chief Complaint

A 59-year-old, right-handed male was admitted to the hospital with a chief complaint of occipital headaches of 4 days duration.

History of Chief Complaint

Three days prior to admission, the patient noted a sudden onset of diplopia on forward gaze and a sensation of dizziness. These complaints resolved within twenty-four hours. He experienced several episodes of dizziness and diplopia over the next 24 hours. One day prior to admission he noted a relatively sudden onset of dizziness, diploia and clumsiness in the right hand. These complaints have persisted since that time.

Medical History

The patient had been under treatment for hypertension for 6 years duration with blood pressures in the range of 180/110.

General Physical Examination

The patient was alert, oriented, and cooperative; he was a well-nourished man of medium height who appeared his stated age. Funduscopic examination revealed clear optic disc with sharp borders. The external auditory canal was patent and uninflamed. Pharynx and larynx were non-reddened. A grade II/W bruit was present over the right carotid artery. His blood pressure was elevated (192/96). Peripheral pulses were intact at the ankle and wrist. Respirations were normal. His chest was clear to auscultation: skin was warm and of normal texture; abdomen was soft with no tenderness, lumps, or masses. No edema was present in the extremities; no lymphadenopathy was present in the cervical or inguinal areas.

Neurologic Examination

Mental Status. The patient was awake and oriented with respect to person, place, and time. Memory was appropriate for his age. Speech was articulate and meaningful and he could follow three and four-step commands.

Cranial Nerves. Extraocular movements were full, but tine patient complained of diplopia made worse by lateral gaze to the left. Nystagmus was present on left lateral gaze. The right pupil measured 3 mm, the left was 5 mm, but both responded to light and accommodation. Ptosis of the right eyelid and decreased sweating on the right side of the face (anhidrosis) were also present. Hearing was diminished in both ears to high frequencies. He admits to a feel of dizziness that he describes as the world moving around him. Pain, but not touch sensation, was decreased on the right side of the face with the exception of some sparing around the lips and nasal region. The right corneal reflex was diminished. Facial expressions were full and symmetric. The uvula deviated to tile left, and there was deficient elevation of the right side of the palate. There was also a suggestion of hoarseness.

Motor System. Strength was intact throughout the body; deep tendon reflexes were intact and symmetric. An ataxia was evident in the right upper extremity on finger-tapping, hand-patting, and finger-to-nose tests. A side-to-side intention tremor was present. Ataxia was also present in the right lower extremity, on heel-to-shin and tibia-tapping tests.

Sensory Exam: He had a mild analgesia to pinprick on the left side of the body, the left "'arm, and the left leg. Position, vibration, and touch modalities were intact throughout the entire body.

 

 

 

QUESTIONS

  1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
  2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
  3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
  4. Are any changes in sensory functions detectable?
  5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
  6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
  7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
  8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
  9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?

 

 

Case Study 3-2

Chief Complaint

This was a 43-year-old, right-handed man with a chief complaint of headaches, slurred speech, and right arm and leg weakness.

History of Chief Complaint

The headaches began 2 weeks ago, and 1 weeks ago he noticed the onset of limb weakness and slurred speech. These symptoms resolved in 12 hours and reoccurred several times in the next 48 hours. Five days ago the neurologic symptoms reappeared rapidly. Currently, the headaches have abated, but the weakness and dysarthria remain.

Medical History

The patient was an accountant in a large business firm and regularly worked 60 to 70 hours per week. He was being treated for hypertension, but admitted to recently decreasing his medications without the consent of his physician. He had a 30-pack-year history of smoking and consumed several ounces of alcohol daily. He denied the use of alcohol during the past 24 hours.

General Physical Examination

This was a well-nourished, alert, oriented man who appeared his stated age. He could comprehend spoken and written language, but had dysarthria. His speech was thickened, as if his tongue was swollen. Heart sounds were normal, blood pressure was high (150'99). Pulse rate and respirations were normal and chest was clear to auscultation and percussion. Abdomen was soft with no lumps, masses, or tenderness.

Neurologic Examination

Mental Status. He was alert and oriented with respect to person, time and place. His speech was dysarthric; however, word-finding ability, comprehension, and repetition were all normal. His reading and writing were appropriate. His fund of knowledge was intact.

Cranial Nerves. His tongue deviated to the left on attempted protrusion. The surface of the tongue on the left side was wrinkled, and muscular fasciculations were present. All other cranial nerves were intact.

Motor Systems. His right upper and lower limbs were noticeably weaker than those on tile left. He had elevated deep tendon reflexes in the right limbs and increased muscle tone in both right limbs. A Babinski reflex was present on the right. All other regions were intact.

Sensory Exam. All sensory systems were intact. There was no loss of pinprick or thermal sensation, no loss of vibratory, discriminative sensation, and no loss of proprioception throughout his body.

 

QUESTIONS

  1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
  2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
  3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
  4. Are any changes in sensory functions detectable?
  5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
  6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
  7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
  8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
  9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?

 

 

Case Study 4-1

Chief Complaint

A 55-year-old right-handed man was brought to the emergency room by his wife because of the sudden onset of slurred speech and difficulty walking.

History of Chief Complaint

He had experienced several episodes of weakness over a two day period prior to his presentation. On the morning of his presentation he experienced a sudden onset of weakness and had fallen in the bathroom, shortly after arising from bed. He was unable to get up from the bathroom floor without his wife's assistance. Once he was up, he found it difficult to walk and that his right arm would not support him as he attempted to lean on the wall. His wife stated that his face looked different.

Medical History

The patient was a professional accountant involved in management. He was married, with three children, one of whom was still living with him. He had enjoyed good health except for elevated blood pressure since turning 45 years of age. He had a 10-pack-year history of smoking but quit all smoking at age 47. He is currently taking no medication.

Family History

His father died at 52 from cardiovascular disease and his mother a 49 from breast cancer. He has a 57-year-old brother who had coronary artery bypass surgery at age 53.

General Physical Examination

This was an alert, oriented, cooperative, and appropriately concerned male with an asymmetric facial expression who appeared his stated age. His eyes were clear with no papilledema; his chest was clear to auscultation and percussion; his respirations, and temperature were normal. His blood pressure 193/98 and pulse rate was 90. Peripheral pulses were present at the wrists but absent bilaterally at the ankles. His abdomen was soft with no signs of tenderness or masses; a large scar in the lower right quadrant of the abdomen was residual from an old appendectomy. His skin was soft and warm, with normal turgor.

Neurologic Examination

Mental Status. The patient was alert, oriented for time and place, and cooperative. His speech was dysarthric, but fluent. Memory, language, and comprehension were intact. He could follow three- and four-step commands. He gave a coherent history.

Cranial Nerves. He denied any double vision, and his visual fields were intact to confrontation. His pupils were 3 to 4 mm in diameter and reactive to light, both direct and consensual. The patient had volitional conjugate vision vertically in both directions and to the right, but not to the left. Both eyes could be deflected to the left side with the doll's head maneuver. Convergence movements in both eyes were intact. He had normal hearing (tested to finger rub) in both ears. His corneal reflex was present on the right, but diminished on the left; however, brushing the left cornea was painful to him. His facial expression was asymmetric. The left side of his mouth was open slightly and did not move when he spoke, his left eyelid would not shut as tightly as the right, and the wrinkles of the left side of the forehead were less pronounced than those on the right. When he attempted to puff out his cheeks, air escaped from the left. side of his mouth. The jaw-jerk and gag reflexes were intact. His palate elevated along the midline and his tongue protruded on the midline.

Motor Systems. Strength was reduced in both extremities on the right compared to those on the left. Tendon reflexes were elevated at the wrist, elbow, knee, and ankle on the right (+3/4) and were normal in all places in the left extremities. Plantar reflexes were extensor; on the right and flexor on the left. No. past-pointing was present on the left, and finger-to-nose and heel-to-shin tests were normal for that extremity. He was unable to execute these tests with the right extremities. His right upper extremity was flexed at the elbow and resisted passive movement; his right lower extremity was extended and resisted flexion, even as he attempted to walk. Normal tone and station were present in the left limbs.

Sensory Exam. Pinprick, light touch, and position and vibratory senses were intact throughout body and face.

The patient was admitted to the hospital overnight for evaluation.

Follow-up

An examination at three months post-first admission finds this gentleman retaining a mild facial asymmetry and elevated deep tendon reflexes in the right extremities. However, strength is 5/5 in all extremities. Conjugate vision on the horizontal axis is in large part restored. He complains of a very mild paresthesia, described as a feeling of "pins and needles" present on the right side of his face.

 

QUESTIONS

  1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
  2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
  3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
  4. Are any changes in sensory functions detectable?
  5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
  6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
  7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
  8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
  9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?

 

 

Case Study 4-2

Chief Complaint

A 49-year-old, right-handed patient called his family physician complaining of clumsiness that began after experiencing a brief loss of consciousness shortly after getting out of bed in the morning.

History of Chief Complaint

He reported that he had suffered severe headaches over the prior 24-hour period and several episodes of instability. He now finds it difficult to walk because his left leg is clumsy. He is also complaining of dizziness accompanied by a loud, roaring sound in his left ear. The patient was transported to the emergency room in the community hospital.

Medical History

He was been diagnosed with hypertension 10 years previous and has been controlled with medication since that time. He is a heavy smoker (25-pack-year history) and consumes 2 to 3 ounces of alcohol daily. Fifteen years ago he was diagnosed with non-insulin dependent diabetes, which has been controlled with diet.

Social History

The patient is married, with two children, and works as a salesman for a large pharmaceutical company.

General Physical Examination

He was awake, oriented, communicative, and concerned with his problem. He was well nourished, well hydrated, and appeared his stated age. Small hemorrhages were present on the retinal discs. The external auditory canal was patent and clear. Pharynx and larynx were non-reddened. The chest was clear to auscultation, blood pressure was elevated (163/102), and pulse rate and respirations were normal. Peripheral pulses were intact at the wrists but only weakly palpable at the ankles; normal tissue turgor was present. Abdomen was soft, with no masses or tenderness. No lymphadenopathy was detected in the cervical, axillary, or inguinal regions.

Neurologic Examination

Mental Status. He was oriented to time and place, with no defect in memory, reading, or writing. Speech was dysarthric, but fluent and meaningful. Word comprehension was good, and he could follow three- and four-step commands.

Cranial Nerves. His visual fields are complete, and he has a full range of eye movements. Horizontal nystagmus was present bilaterally. His pupils were symmetric and reactive to light, both direct and consensual. Convergence movements in both eyes were intact. Hearing was markedly reduced in the left ear, and he had poor word discrimination ability in the left ear compared to that in the right. He complained of a vertiginous sensation of the world drifting around him. He related the change in his hearing and the onset of the vertiginous feeling to his morning event. He had a dense analgesia for pinprick over most of his face on the left except for the perioral regions. Some loss of sensation for pinprick was also present on the right, but it was less dense than that on the left. He also complained of a painful paresthesia on the right side of his face that he described as a feeling of having pins and needles on his skin. Corneal reflex was absent on the left and reduced on the right. Jaw-jerk reflex was normal. Two-point discrimination and vibratory sense were normal throughout the face bilaterally. He had no tone in the facial muscles above or below the eye on the left. Creases in his forehead were asymmetric, and the only right side wrinkled on an attempted smile. On attempted upward gaze only the right eyebrow elevated. The left corner of his mouth was open 0.5 cm at rest, and the left eye would not shut completely on attempted blink or squint. Gag reflex was normal, and he denied any dysphagia. Although his speech was slurred, his voice had normal tone, volume, and emotion. His tongue protruded on the midline and appeared normal.

Motor Exam. Strength and reflexes were normal and symmetric in all four limbs, and plantar responses were flexor in both lower limbs. Finger-to-nose and heel-to-shin testing were normal on the right, but grossly abnormal on the left side. Past pointing was present in the left limbs. A left pronator drift was seen when the arms were outstretched.

Sensory Exam. Two-point discrimination, vibratory sense, and proprioception were normal throughout the body. Pinprick and thermal sensations were normal on the left but absent on the right side of the arm, trunk, and leg.

Follow-up

An examination at 2.5 months post-first admission finds the patient with a persistent left facial asymmetry. The left eye will close weakly, but the left corner of his mouth still does not move on attempted speech or on grimacing. He complains of a paresthesia on the left side of his face and left extremities and response to pin prick testing is blunted in all of these regions. The past pointing, present on the initial exam, has resolved from the left limbs.

 

QUESTIONS

  1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
  2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
  3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
  4. Are any changes in sensory functions detectable?
  5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
  6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
  7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
  8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
  9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?

 

 

Case Study 5-1

Chief Complaint

A 36-year-old attorney was referred with a chief complaint of headaches and vomiting.

History of Chief Complaint

The patient had had frontal and biparietal headaches for approximately one month. Coughing, sneezing, or bending precipitated the headaches. On at least one occasion the patient had been awakened by a headache. He experienced nausea and vomiting independent of the headaches. At times, vomiting occurred suddenly without preceding nausea. For several weeks prior to admission he had been unsteady on his feet with a tendency to fall to the right. He admitted to occasional clumsiness of his right hand. During the week prior to admission he had been excessively drowsy and constantly tired. The headaches had become more frequent, so that they were now occurring three to four times per day.

Medical History

His medical history was unremarkable except for an episode of rheumatic fever at age 6.

Family History

He was unmarried, lived alone, and was employed by a large law firm. His parents were alive and in good health; he had no siblings.

Social History

He professed to be heterosexual and was involved in a monogamous relationship that had lasted for several years. He had a 10-pack-year history of smoking, but had quit 6 years previously. He had been active in outdoor sports since age 31 and had been running up to 4 miles daily until 4 weeks before, when he had to quit because of an unsteady gait and headaches.

General Physical Examination

This was an awake, oriented, well-nourished, well-hydrated, and distressed man in considerable pain. He appeared the stated age and in otherwise good physical condition. His eyes had no cotton wool patches, but papilledema was evident. His chest was clear to auscultation and percussion; his abdomen was soft without lumps or masses. Blood pressure, pulse rate, temperature, and respirations were normal. Peripheral pulses were intact; no edema was present; and no cervical, axillary, or inguinal lymphadenopathy was detected.

Neurologic Examination

Mental Status. He was awake and oriented with respect to person, place, and time. His memory and knowledge base were appropriate for his training. Speech was fluent and meaningful. He was a coherent historian.

Cranial Nerves. His pupils were 3 to 4 mm in diameter and reactive to light, both direct and consensual. On funduscopic examination there was evidence of bilateral papilledema. Horizontal nystagmus in the direction of gaze was present on attempted lateral gaze to either side. He denied any double vision. Hearing was normal and equal in both ears. Corneal, jaw-jerk, and gag reflexes were intact. Facial expressions were full and symmetric. Uvula and tongue protruded on the midline. Shoulder shrug was symmetric.

Motor Exam. His strength was intact in all extremities and his deep tendon reflexes were symmetric and physiologic. His plantar responses were flexor. When walking, he kept maintained a slightly widened base and there was a mild tendency to veer to the right. He was unable to stand on his right leg comfortably. Closing his eyes did not markedly alter his instability on his right leg. He could stand comfortably on his left leg with his eyes open or shut. A very mild end-point tremor was present in the right upper extremity, on finger-to-nose testing and in the right lower extremity on heel-to-shin testing. Alternating movements of the right hand were slightly slower and with prolonged periods, became disorganized (dysdiadochokinesia).

Sensory Exam. Pinprick, two-point discrimination, vibratory sense, and proprioception were intact throughout body and face.

 

QUESTIONS

  1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
  2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
  3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
  4. Are any changes in sensory functions detectable?
  5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
  6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
  7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
  8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
  9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?

 

 

Case Study 5-2

Chief Complaint

An 8-year-old girl was brought to her family physician by her mother because the child has become "unsteady" when walking .

History of Chief Complaint

Seven months earlier, she had begun complaining of nausea frequently. She is still complaining of nausea, but she is also vomiting frequently. In the past 3 months, the child has begun walking unsteadily with a broad-based gait. When seated, she swayed from side to side and occasionally fell over. Her head rotated from side to side as her body swayed. The mother also noted that the child had recently become extremely irritable.

Developmental and Medical History

The mother had had an uneventful pregnancy and delivery. At birth the child weighed 3.25 kg; by 5.5 months she could maintain a seated, upright posture, and she could roll over at 6 months of age. She could rise to a standing position and take several steps by 15months and could climb stairs by 20 months. By 3 years of age she could stand on one foot, unassisted. For the next 4 years she was active in outdoor play. All of her immunizations were current.

Family History

The mother is a social worker for the state and a single parent; the father is remarried and lives out of state. The child's maternal and paternal grandparents were in good health. The mother had a 12-pack-year history of smoking and smoked through the pregnancy; she denied any use of alcohol or drugs either at this time or during the pregnancy. No one else in her family had similar or related symptoms.

General Physical Examination

This was an awake, oriented child who was complaining of headaches and dizziness. Face and personality appeared the stated age, but she was underweight and lacked appropriate muscle mass. Edges of optic discs were blurred, but lacked cotton wool patches or papilledema. Nystagmus was evident on lateral gaze to either side. Her chest and abdomen were normal; blood pressure, pulse rate, temperature, and respirations were physiologic. Peripheral pulses were intact, with normal tissue turgor, and no cervical, axillary, or inguinal lymphadenopathy was detected.

Neurologic Examination

Mental Status: The child was awake and oriented with respect to time and place. Memory and knowledge were appropriate for her age. However, response time to questions was protracted and she appeared preoccupied with her headache pain.

Cranial Nerves. She had a full range of eye and facial movements. However, nystagmus was present on horizontal gaze to either side. Hearing was normal in both ears. Corneal, jaw-jerk, and gag reflexes were normal. The facial expressions were complete, the eyes were closed tightly, and the forehead was wrinkled symmetrically when frowning. Uvula and tongue protruded on the midline.

Motor Exam. Strength was normal in all extremities; deep tendon reflexes were physiologic in all extremities. In the seated position, the child swayed from side to side and could not maintain her torso in a vertical position. Her gait was broad-based and reeling. However, finger-to-nose and heel-to-shin testing were grossly abnormal except if her torso was supported in a vertical position.

Sensory Exam. Pinprick, thermal, vibratory, two-point discrimination, and proprioceptive senses were normal throughout the body and face.

 

QUESTIONS

  1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
  2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
  3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
  4. Are any changes in sensory functions detectable?
  5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
  6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
  7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
  8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
  9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?

 

 

Case Study 5-3

Chief Complaint

A 49-year-old man was admitted to the hospital after experiencing the rapid onset of acute gait imbalance for 3 days ago.

History of Chief Complaint

He had spent Sunday doing light work in the yard and that evening suddenly developed a severe headache. It is his impression that the difficulty walking also developed at that time. Over the next 3 days the headaches gradually remitted somewhat, but the gait imbalance has persisted unchanged. He notes that he tends to lean to the left on standing or walking. He currently is experiencing a mild headache, but denies any vertigo. He denied any history of neck trauma. Vomiting had occurred once or twice late Sunday night, but has not reoccurred.

Family History

He was married, with two children, both of whom were in college. His mother was alive and in good health; his father had died from a myocardial infarct at the age of 60.

Medical History

He had had diabetes since childhood; control was maintained daily with insulin. He had recently experienced visual loss and numbness in his toes. He has a history of mild hypertension that has been controlled with pharmaceuticals for the past 3 years.

General Physical Examination

He was an awake, oriented, and afebrile male, appearing his stated age and of appropriate weight. He was well nourished; his skin had good color, texture, and temperature. He had several small bruises on his left foot. Optic discs had numerous microaneurysms, with several surrounding deep hemorrhages and scattered hard exudates. A bruit was noted over the left carotid artery. Chest was clear to auscultation and percussion; abdomen was soft with no masses or lumps. Blood pressure, pulse, temperature, and respirations were normal on the date of admission.

Neurologic Examination

Mental Status: He was awake and oriented to time and place. Memory and knowledge were appropriate. He was mildly dysarthric.

Cranial Nerves: Eye movements were full, with left-beating nystagmus on gaze to the left, more marked in the left than in the right eye. The left pupil was smaller than the right; both pupils reacted normally to light. The left palpebral fissure was greater than the right. Normal hearing to finger rub was present in both ears, and he denied tinnitus. He had diminished sensation to pinprick on the right side of his face, with slightly diminished corneal reflex on the right. Pinprick sensation and corneal reflex on the left were intact. His gag and jaw-jerk reflexes were intact. He had a mild paralysis of the facial muscles around the corner of his mouth on the right. His palate elevated on the midline and his tongue protruded on the midline.

Motor Exam: Limb strength and reflexes were physiologic in all extremities. Past-pointing was present on finger-to-nose testing in the left upper extremity and on heel to shin testing in the lower extremity. He demonstrated a mild end point intention tremor on purposeful movements in the left upper extremity. On attempted synchronous rapid alternating movements of the hands, the left hand moved slower. Left pronator drift was evident, and he deviated to the left on walking.

Sensory Exam: Vibratory, two-point discrimination, and proprioceptive senses were intact throughout the body. Pinprick sensation was intact on the left side of his body but diminished in the upper and lower extremities on the right.

 

QUESTIONS

  1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
  2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
  3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
  4. Are any changes in sensory functions detectable?
  5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
  6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
  7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
  8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
  9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?

 

 

Case Study 6-1

Chief Complaint

This 57-year-old, right-handed woman is presenting with a marked weakness of her right eyelid and double vision when her eye is forced open.

History of Chief Complaint

She had experienced two episodes of blurred vision and headache on the day prior to admission. That evening she went to bed early. She awoke with an inability to open the right eyelid. When she held the eyelid open with her finger, she noted marked double vision. Upon arising from the bed she noted difficulty walking.

Medical History

This patient had had moderate hypertension for 30 years. The hypertension was managed using beta-blockers. Five years previous she had experienced several episodes of transient right-hand weakness and paresthesia and dysartheria. Two year prior, she experienced an episode which involved right-hand weakness and paresthesia and dysartheria and lasted for 15 minutes. This episode was accompanied by blurring of vision. Examination at that time revealed slightly elevated deep tendon reflexes on the right side.

Family History

The patient has been married for 35 years and has three children in college. Both parents are living; her father has had a long history of hypertension. She has a 25-pack-year history of smoking and claims to consume a moderate amount of alcohol each week.

Physical Examination

She was awake, oriented, and of anxious demeanor. The patient was well nourished, well hydrated, obese, and in poor physical condition; she appeared slightly older than her stated age. Optic discs had sharp edges. Her chest was clear to auscultation and percussion. Her blood pressure was 160/100; pulse, temperature, and respirations were physiologic. Abdomen was difficult to palpate because of her obesity; however, no tenderness was observed. Peripheral pulses were difficult to access; mild edema was present at the ankles but not at the wrists.

Neurologic Examination

Mental Status. The patient was alert and oriented to time and place. Speech was articulate and speech content was meaningful. Memory and knowledge were appropriate for her background. She could follow two- and three-step commands and was an adequate historian.

Cranial Nerves. Visual fields were full to confrontation. If asked to open her eyes, the right eyelid did not elevate beyond 2 mm; the left opened 10 to 12 mm. When the right eyelid was elevated by external force, the right eye was deviated to the right and down; she could effect no medial or upward movement of the right eye. The right eye did not respond to caloric testing, nor did it respond during attempted convergence. A full range of motion was present with the left eye. Pupillary responses were intact bilaterally. Although it did not move, the right eye would dilate with the left eye on attempted convergence. Hearing was normal in both ears. A minor weakness was noted in the left corner of her mouth when she attempted to grimace. Her palate elevated symmetrically, and corneal, jaw-jerk, and gag reflexes were intact. Her tongue protruded on the midline and her shoulder shrug was symmetric and of physiologic strength.

Motor Exam. Strength was intact in all limbs. Deep tendon reflexes were physiologic and symmetric in both lower extremities and the right upper extremity; the left upper extremity had 3/4 reflexes at the elbow and wrist. The abdominal reflex was absent on the left.

Sensory Exam. Pinprick, two-point discrimination, vibratory sense, and proprioception were present throughout face and body bilaterally.

Follow-up

A follow-up examination at 4 months post-admission finds the restoration of movement in the right eye in all directions with only minimal residual diplopia on extreme left lateral gaze. Both eyes could open fully. The mild facial asymmetry had resolved. Strength was equal in all extremities with normal deep tendon reflexes everywhere except for left upper limb with brachioradialis reflexes at 3/4. The abdominal reflex was present bilaterally.

 

QUESTIONS

  1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
  2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
  3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
  4. Are any changes in sensory functions detectable?
  5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
  6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
  7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
  8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
  9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?

 

 

Case Study 6-2

Chief Complaint

A 79-year-old, right-handed retired business, executive was brought to his general practitioner's office by his son after suffering a momentary loss of consciousness followed by the development of double vision and a tremor in his left arm.

History of Chief Complaint

He complained of frequent dizzy periods over the last 5 days. The dizzy episodes were occasionally accompanied with diplopia. On the morning of admission, he had experienced a brief period of syncope upon arising from bed. After regaining consciousness he complained of a pronounced and persistent double vision.

Past Medical History

He had been married for 40 years; his wife had died 5 years earlier. He had been an executive for a large firm. After retirement he has been active socially and played sports. His past medical history was positive for rheumatic fever at age 6. For the past 5 months he had been experiencing periods of dizziness and fatigue. He had a 30-pack-year history of smoking, but quit completely 3 years before. He drank 2 to 3 ounces of alcohol socially per week.

General Physical Examination

He was alert and oriented, well nourished, and of average weight; he appeared his stated age. The patient frequently had to cover his right eye with his hand in order to move about the room. Optic discs were clear with sharp borders. External auditory canals were patent. His neck was supple; there where no bruits over the carotid artery. His larynx and pharynx were non-reddened. His chest was clear to auscultation and percussion; abdomen was soft without rigidity, tenderness, or organomegaly. Heart rate was irregularly irregular. Peripheral pulses were intact; a pulse deficit was present, with the auscultated apical rate exceeding the radial pulse rate. Blood pressure was 135/93, temperature was 37°C, and respirations were 16/min. No cervical, axillary, or inguinal lymphadenopathy was present.

Neurologic Examination

Mental Status: The patient was alert and oriented to time and place with memory and knowledge appropriate for his age. He was articulate in speech and had good comprehension of spoken and written language. He gave a comprehensive history.

Cranial Nerves: On forward gaze, with the lid forcibly elevated, the right eye had an external strabismus; on attempted left lateral gaze, the right eye drifted toward the midline. The right pupil was larger than the left. The right pupil was unresponsive to light shined in either eye; the left pupil was responsive to direct and consensual light. The right eyelid elevated 4 mm, whereas the left elevated 13 mm on forward gaze. With the right eyelid forcibly elevated, its visual field was full to confrontation. The visual field in the left eye was also full. The patient noted diplopia on attempted vision into all fields of gaze. The diplopia was absent with the right eye covered and exacerbated when the right eyelid was fully elevated. Hearing was normal in both ears. He had a full range of facial expressions. Jaw-jerk and corneal reflexes were normal; the palate was elevated on the midline; gag reflex was normal; and tongue protruded on the midline.

Motor Exam: Strength was normal in all limbs; deep tendon reflexes were +2/5 on the right and +3/5 on the left. No Babinski response was present. A tremor of intent was present in the left arm. Finger-to-nose testing was normal on the right, but he was slightly off target when using the left upper limb. The left arm and hand displayed an occasional jerky movement that the patient could not suppress.

Sensory Exam: Pinprick and temperature sensation were normal throughout body and face; position sense and vibratory sensation on the left side of his body was diminished. This sensory loss was more noticeable in the upper than in the lower extremity.

 

QUESTIONS

  1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
  2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
  3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
  4. Are any changes in sensory functions detectable?
  5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
  6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
  7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
  8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
  9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?

 

 

Case Study 7-1

Chief Complaint

This 65-year-old, right-handed man was brought to the emergency room early in the morning by his family. They complained that he was confused and had difficulty communicating with them. He had been that way since shortly after he awoke that morning.

History of Chief Complaint

He was in good health until 7 years before, when he was diagnosed as having hypertension. One year later he was admitted to the community hospital, the day after he experienced a brief episode of quadriparesis, blurred vision, and nausea. At that time Doppler studies of the carotids were normal, as were lumbar puncture, electroencephalogram, and a computed tomographic (CT) scan. Diabetes was detected and he was given a regimen of insulin and discharged. During the next 4 years, no known transient ischemic episodes occurred. The day prior to this most current admission, he had complained of intermittent weakness in his right hand.

Family History

At the time of admission he was married, retired from military service, and had two children, both of whom are married. His father had had hypertension and died at 55 of coronary artery disease; his mother was still living.

General Physical Examination

He was a well-hydrated, well-nourished man in no acute distress who appeared the stated age. Funduscopic examination revealed arterial-venous nicking without hemorrhage or papilledema. His heartbeat was regular without murmurs or gallops. Blood pressure was 180/100. Respiration and pulse were normal. Lungs were clear to auscultation. Abdomen was soft without masses. Skin was of good texture and temperature. Several small areas of active keratosis on the right posterior scalp were evident.

Neurologic Examination

Mental Status: He was disoriented with respect to time, place, and personal information, relying on his family members to supply much of the history. He had impaired recent memory and fund of knowledge. (He said Kennedy was president.) He confused the left and right sides of his body. A mild sensory neglect, detectable with extinction testing, was apparent on his right side. His speech was poorly articulated and perseverative, and he used word substitutions and mispronounced words frequently; however, he had normal repetition of speech.

Cranial Nerves: He had a full range of eye movements. There was a right homonymous hemianopsia. Pupils were symmetric and bilaterally responsive to light both direct mad consensual. Hearing was normal in both ears. Corneal, jaw-jerk, and gag reflexes were intact. His face was asymmetric on spontaneous emotional expression (e.g., smiling), but not on voluntary movement (right "emotional" facial paralysis). Discriminative touch was intact across his face, bilaterally. The uvula was elevated on the midline; the tongue protruded on the midline. Shoulder shrug was symmetric.

Motor Systems: Strength in the limbs was +5/5 in the left arm and leg and +3/5 in the right arm and +4/5 in the right leg. Deep tendon reflexes were elevated in the right arm more than the right leg; they were physiologic on the left. A Babinski sign was noted on the right.

Sensory Exam: Pain, light touch, and vibration sense were normal, but discriminative touch and proprioception were impaired in the right hand.

Follow-up

The patient remained in the hospital for five days, during which he some of the confusion cleared and he no longer demonstrated any signs of the neglect syndrome. He was discharged to physical and occupational therapy for assistance with basic functions of living. Re-examination at six months post-discharge finds a persistent right homonymous hemianopsia and mild right-sided weakness with slightly elevated deep tendon reflexes, but normal facial symmetry on emotional stimuli.

 

QUESTIONS

  1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
  2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
  3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
  4. Are any changes in sensory functions detectable?
  5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
  6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
  7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
  8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
  9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?

 

 


 

Case Study 7-2

Chief Complaint

A 47-year-old, left-handed man was admitted to the hospital with a primary complaint of chest pain of 3 weeks' duration. He also complained of a increasing loss of vision.

History of Chief Complaint

He had a recent history of angina on exertion, and electrocardiographic analysis documented an acute myocardial infarct. Since childhood he had consumed at least a gallon of water a day and had had thirst, polyuria, and nocturia. Having grown up with these symptoms, he had considered them normal.

Family History

At the time of admission, he was not married, lived alone, and admitted to having very little libido throughout his life. His mother, father, and two siblings were alive and in good health. No one else in his family had exhibited his chief complaints.

General Physical Examination

He appeared to be a well-hydrated, well-nourished man, alert but with an anxious demeanor. He appeared his stated age. He weighed 240 pounds and his height was 66 inches. His head was normocephalic. Funduscopic examination revealed normal cup-to-disc ratio; soft cotton wool patches were noted two disc spaces from the disc in the superior temporal retina bilaterally; no aneurysms, hemorrhages, or papilledema was evident. His heartbeat was regular without gallops or thrills; an SII systolic murmur was noted at the left sternal border. The apex beat was displaced to the left. Abdominojugular reflux was noted on application of abdominal pressure. Respiration was labored, breath sounds were decreased; crackles and wheezes were heard at the base of the lungs on auscultation. The abdomen was soft, without masses or tenderness. Temperature was elevated at 37.5°C and oscillated between 37.3°C and 37.9°C over a 24-hour period. Skin was moist with good texture and turgor. Pretibial edema (+2) was present in the lower extremity.

Neurologic Examination

Mental Status: The patient was awake and oriented for time and place; memory and knowledge were appropriate for his education. His speech was articulate and meaningful. Although he was cooperative most of the time, he experienced bouts of rage when he yelled at the attending staff and physician.

Cranial Nerves: He had a full range of eye movements, visual acuity was normal in the center of his fields but diminished rapidly to the sides, vision in the temporal fields was absent altogether. Corneal, jaw-jerk, and gag reflexes were intact. His face was symmetric, with normal expression on emotion. Hearing was diminished in the right ear more than in the left. Uvula and palate were symmetric and elevated on the midline; the tongue protruded on the midline. Shoulder shrug was symmetric.

Motor Systems: Gross motor strength was equal in upper and lower extremities; deep tendon reflexes were 2/4 and equal in upper and lower extremities. Babinski response was physiologic with no muscular atrophy or hypertrophy. No drift or involuntary motion was detected.

Sensory Exam: There was no loss of vibration or proprioceptive sense, and no loss of pain or thermal senses was evident.

Follow-up

During his hospital admission, marked thirst and daily intake of 4000 to 17,000 mL of fluid were noted. Urine outputs of 3500 to 18,000 mL daily were recorded. The specific gravity of his urine was always below 1.005. One month after admission, the patient died of congestive heart failure.

 

 

 

QUESTIONS

  1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
  2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
  3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
  4. Are any changes in sensory functions detectable?
  5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
  6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
  7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
  8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
  9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?

 


 

Case Study 7-3

Chief Complaint

This 55-year-old man experienced a sudden onset of numbness in his left upper limb while eating supper. When it persisted, he consulted his family physician.

History of Chief Complaint

At the time of examination he was unmarried and worked in a factory performing quality-control inspections. Both of his parents were alive, and he had lived with them all his life. He was diagnosed with myotonic dystrophy at 33 years of age; its course had been a slow, progressive increase in proximal muscle weakness since that time.

General Physical Examination

The patient was an awake, alert, oriented man with significant muscle wasting, especially in the proximal limb muscles. His movements were punctuated by occasional tonic muscle contractions of considerable force. He appeared older than his stated age. The center of the lens in each eye was significantly, grayed obscuring observation of the optic discs. His blood pressure, respiration, and temperature were all within normal ranges. His chest was clear to auscultation; the abdomen was soft, with no tenderness. A reducible mass was present in the inguinal region on the right. The cataracts, myotonia, and proximal muscle weakness are of long duration.

Neurologic Examination

Mental Status: He was awake and oriented for time and place. Normal mental status was found on all tests except for a short-term visual memory deficit discovered during a neuropsychological examination at a latter date; there was no significant amnesia or aphasia.

Cranial Nerves: Visual fields were full to confrontation, however, visual acuity was poor. A full range of eye movements was possible, and no nystagmus was present. Facial expression was full, and smiling was symmetric. His hearing was normal in both ears. Jaw-jerk and corneal reflexes were physiologic. The palate was elevated midline, and tongue protruded midline. Shoulder shrug was bilaterally symmetric. Swallowing and voice were normal.

Motor Systems: Extended periods of tonic muscle contractions followed some of his movements; these lessened with repetitive motion. Muscle strength was diminished, with considerable wasting present in the proximal muscles of the shoulders and pelvis. His tendon reflexes were diminished but symmetric in all extremities, and plantar reflexes were flexor. His left-hand exhibited athetoid movements but only when he closed his eyes.

Sensory Exam: He had loss of sensation on the left side of his torso and face and left extremities for pinprick, light touch, proprioception, vibration, two-point discrimination, graphesthesia, and stereognosis. There was an abrupt vertical boundary to the sensory loss along the midline of the torso. No hyperesthesia or dysesthesia was noted.

 

 

QUESTIONS

  1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
  2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
  3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
  4. Are any changes in sensory functions detectable?
  5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
  6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
  7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
  8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
  9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?

 

 

Case Study 7-4

Chief Complaint

This 78-year-old woman was brought to the emergency room from a local nursing home after she became very agitated and disoriented, alarming the other residents.

History of Chief Complaint

At the time of admission she had been retired for 13 years from her position as an elementary schoolteacher. She had been married, and her husband was deceased. She had no children. Five years previously she had moved from her house to a nursing home. Two years previously she had experienced a period of right facial weakness with language dysfunction; this had resolved over a 2-week period. Until the day of admittance she had been a pleasant person, sociable with other residents of the nursing home, and with good memory.

General Physical Examination

She was in an agitated state and uncooperative, making a detailed examination difficult. She was well nourished and well hydrated and appeared her stated age. She had increased pulse, respiration, and blood pressure (190/100 mmHg). She appeared flushed, and her skin was moist.

Neurologic Examination

Mental Status: She was disoriented with respect to time and place. She insisted she was going shopping and that the driver had let her out at the hospital by mistake. She was aggravated and abusive with the attending personnel. She was a poor historian. At the time of admission she could not be tested for memory, since she refused to answer most questions.

Cranial Nerves: Visual fields appeared full to confrontation, a full range of eye movements was possible, and no nystagmus was present. Facial expression was full and hearing was normal. Jaw-jerk reflex was normal, and corneal reflex was present. Palate was elevated midline, and tongue protruded midline. Shoulder shrug was bilaterally symmetric. Swallowing and voice were normal.

Motor Systems: Movements were normal; strength and deep tendon reflexes were physiologic throughout the patient's body.

Sensory Exam: Response to pinprick was normal; no detectable loss of proprioception was found. Testing was complicated by her uncooperative nature.

Follow-up

The patient was insomnic for 3 days while under observation in the hospital. On discharge to the nursing home she was calm but had marked memory dysfunction and continued to confabulate explanations covering the memory loss. One month after returning to the nursing home she developed hypersomnia and was difficult to arouse. She returned to the hospital, where she died 1 week later.

 

QUESTIONS

  1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
  2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
  3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
  4. Are any changes in sensory functions detectable?
  5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
  6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
  7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
  8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
  9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?

 

 

Case Study 8-1

Chief Complaint

This is a 73-year-old, right-handed male who developed a paralysis and an inability to speak.

History of Chief Complaint

The patient was in excellent health until 7 o'clock on the evening of his admission, when he suddenly dropped his pipe out of his right hand while sitting on back porch of his daughter's house. Although he did not experience a syncopal episode, his family reported that he was obtunded for a few minutes. Since this episode, he has been unable to speak. He was brought directly to the emergency room.

Social History

At the time of admission, the patient had been retired for 4 years from his position as an executive with a large firm in the southern portion of the country. He had been active in recreation for the past 10 years. He was in Leeds, Maine visiting his daughter's family as part of an extended vacation touring the country in a recreation vehicle.

Medical History

His medical history was unremarkable. There was no history of peptic ulcer disease or of any previous myocardial infarction or rheumatic fever.

General Physical Examination

The patient was an elderly male who appeared younger than his stated age. He was alert, cooperative, and followed two- and three-step commands. His neck was supple with bilateral high-pitched carotid / bruits. No hemorrhages were present in the conjunctiva. No nail-bed hemorrhages were present. Heart was regular with no murmurs, rub, or gallops. No easy bruising, bleeding, hematochezia, hemoptysis, or hematuria were noticeable. He denied any stomach pain: Skull and spine were atraumatic. No cranial or orbital bruits were heard. Also, no history of migraine or other pervious neurologic illnesses was given.

Neurologic Examination

Mental Status: The patient was awake and oriented to place and time. He had a markedly decreased output of speech and answered only in monosyllables of yes or no. If asked for names, he pointed to the object or person, rather than responding with the word. By using yes or no responses and by following commands, he could demonstrate that he comprehended spoken and written language. He was incapable of writing his name or the days of the week, but could point to the correct day from a list. He quickly recognized family members and attending hospital staff as they entered the room. He could follow two- and three-step commands accurately with his left arm and hand.

Cranial Nerves: The optic disks were flat; visual fields were intact. No hemorrhages or other embolic phenomenon were present. He had a full range of extra-ocular motion. His pupils had a range of motion of 2.5mm to 1.5 mm to both direct and consensual light reflexes. Both eyes could close tightly. At rest, his eyes deviated into the left visual field. Wrinkle lines were symmetric across the forehead, and eyebrows elevated symmetrically. The lower right quadrant of his face showed some paresis when he was asked to grimace or smile. Corneal, jaw-jerk, and gag reflexes were intact. His uvula elevated symmetrically, his tongue protruded along the midline, and his shoulder shrug was symmetric.

Motor Systems: Motor examination reveals a right upper limb monoparesis with a right pronator drift. Motor power was approximately 4+/5 in the right upper extremity. Motor power in the right leg was 5/5. There was right hyper-reflexia in the upper extremity, and the right toe was up-going.

Sensory Exam: Sensation to touch, vibration, proprioception, and pain were decreased on the right arm and thigh but was intact on the left side of his body. This portion of the examination was somewhat equivocal because of the patient's poor communication skills.

Follow-up

After two days hospital care, the patient was discharged to his daughter’s care in Leeds, Maine and three weeks later he and his wife returned to their home in South Carolina. On check-up examination three months post-discharge, the patient presented with normal strength in all four extremities with slightly increased deep tendon reflexes in the upper right extremity. Eye movements were complete to all fields and resting ocular position was midline. His speech was meaningful and clear but he occasionally experienced difficulty expressing a word or phrase.

 

QUESTIONS

  1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
  2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
  3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
  4. Are any changes in sensory functions detectable?
  5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
  6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
  7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
  8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
  9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?


 

Case Study 8-2

Chief Complaint

This 52-year-old, right-handed male with confusion and weakness

History of Chief Complaint

was brought to the emergency room by ambulance after losing consciousness in a restaurant on a Sunday afternoon. Although he maintained vital signs, he remained unconscious for 2 days, after which he began responding to external stimuli. Over a 2-week period be gradually regained consciousness. At this point he was re-examined for evaluation of future course.

Medical History

He had been in good health up until the apoplectic episode.

Social History

At the time of admission he was a post office employee, married, with three children, all in high school and living at home. His family stated that he did not smoke but admitted that he drank three or four glasses of beer per week.

Family History

His father had died of cerebrovascular disease 10 years before, at the age of 64, his mother was living and in good health.

General Physical Examination

The patient was a well-nourished, well-hydrated male with male-pattern baldness and appeared his stated age. He was awake and fully cooperative but was disoriented for time and place. He had difficulty recognizing family members and hospital staff. He was overweight and appeared anxious. His optic discs were clear and sharp, and visual acuity was good. The neck was supple, with no bruits or lymphadenopathy. The chest was clear to percussion; the abdomen was soft, with no masses or tenderness. Peripheral pulses were intact at the wrist and ankle. Skin was moist and warm.

Neurologic Examination

Mental Status: The patient was an awake, fully cooperative, but disoriented male. His volitional speech was extremely nonfluent, consisting of several short phrases, such as, "no… no... no... no... no" or "tat... tat.., tat." He repeated these phrases many times when attempting to answer questions. He could, however, repeat complicated phrases following the examiner's lead, such as "no ifs, ands, or buts." Yet he could not recite the days of the week or months of the year when asked. Although he could understand simple commands (e.g., "Point to the door"), his comprehension of language was extremely poor. He never understood two- or three-step commands. He could read a few words aloud but could not comprehend what he had read; he could not write or draw even simple figures.

Cranial Nerves: He had a full range of eye movements but tended to keep his eyes positioned to the left when resting. Visual acuity was difficult to test, but he was capable of reading 8-point type. Both pupils were reactive to light, direct, and consensual. Hearing could not be tested accurately. Corneal, jaw-jerk, and gag reflexes were intact. There was a mild weakness in the right lower quadrant of his face. The uvula was elevated on the midline, and the tongue protruded on the midline. Snout, grasp, and suck reflexes were not present.

Motor Systems: Strength was diminished on the right, more so in the leg than in the arm. Deep tendon reflexes were elevated on the right compared to the left. A Babinski sign was present on the right, lie was incontinent for urine and feces and was visibly upset when this occurred.

Sensory Exam: The sensory exam was difficult due to the patient's poor mental status. Pinprick, temperature, vibratory, and proprioceptive senses appeared intact throughout the body and face, with the exception of some loss in the lower extremity on the right.

 

QUESTIONS

  1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
  2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
  3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
  4. Are any changes in sensory functions detectable?
  5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
  6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
  7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
  8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
  9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?

 

 

Case Study 9-2

Chief Complaint

This is a 55-year-old, male severe memory loss following cardiac surgery.

History of Chief Complaint

The patient had been a government worker who was retired due to medical disability. During coronary surgery he suffered several extended periods of anoxia and has experienced severe neurologic consequences. He is presenting for a checkup, 4 years post-operative.

Medical History

Five years ago, this patient was diagnosed with coronary artery occlusion, and bypass surgery was performed. During recovery, an atrial tear resulted in a significant loss of blood. The patient experienced a 15-minute period of hypoxia. The tear was repaired; however, during this second trip to the operating room, the patient's EEG was fiat and his pupils were fixed. The following day, a third trip to the operating room was required by further bleeding; again his pupils were fixed and the EEG was diminished in amplitude. Over the next 2 days the patient gradually regained consciousness. He had reduced strength and paresthesia in the left arm. He also demonstrated severe memory, loss and confusion with respect to time and place. Prior to the surgical event, he had had no history of neurologic signs or symptoms.

General Physical Examination

This was a well-nourished, well-hydrated, obese male who was alert and cooperative and in no acute distress. Carotid auscultation revealed a soft bruit without radiation on the right. Heartbeat was regular; a grade III harsh systolic murmur, auscultated best at the second intercostal space on the right, with an S3 gallop was present. Peripheral pulses were intact. Lungs were clear to auscultation and percussion. The abdomen was soft, without masses, tenderness, rigidity, or rebound. A +2 peripheral, dependent edema was noted in the lower extremities bilaterally. Skin was sallow in appearance, with poor texture and turgot. A well-healed cicatrix of the anterior chest wall extended from the second intercostal space to the diaphragmatic area; a healed 2-em cicatrix was noted in the left antecubital fossa; and a healed 1-cm cicatrix was loomed in the left subclavicular area.

Neurologic Examination

Mental Status: The patient was disoriented with respect to time and place and could not describe the reason for his past hospital confinement or recall the history of his illness. However, his speech, naming, reading aloud, and comprehension were all normal for his age. He rapidly forgot information recently expressed to him; he could not recognize any words presented to him 5 minutes previously. He could not recall the names of staff and physicians in either the office or the hospital. Prior to his illness, he had had a strong interest in American history and politics. During the examination he could recall most of the president's names and supply some details concerning their era, but he could not identify the current president or describe any recent historical events. He frequently relied on his family members to provide any recent descriptions of his life. He did not recall why he was ill or any of the events occurring around the time of his cardiac surgery. No other significant personality changes or cognitive deficits were detectable in the patient.

Cranial Nerves: His visual fields were full to confrontation; funduscopic examination revealed AV nicking and silver wire changes without exudates, hemorrhages, or papilledema. His hearing was slightly diminished in both ears. A full range of facial expression was present, and the jaw-jerk reflex was normal. Palate and uvula elevated symmetrically, and tongue protruded on the midline.

Motor Systems: Although the patient had motion in all extremities, strength was diminished on the left side, with slightly elevated deep tendon, reflexes and a Babinski sign. Strength in the left upper extremity was 3/5 and 5/5 the left lower extremity.

Sensory Exam: Vibratory sense, proprioception, and discriminative touch were diminished but not absent in the left and normal in the right extremities. Paresthesias, described as tingling sensations, were found involving the patient's left hand and forearm.

 

QUESTIONS

  1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
  2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
  3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
  4. Are any changes in sensory functions detectable?
  5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
  6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
  7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
  8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
  9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?

 

 

 

Case Study 9-3

Chief Complaint

A 33 year-old man with hallucinations and amnesia is brought into the emergency room by the police.

 

History of the Chief Complaint

A 33 year old unemployed migrant worker was brought to the emergency room by police. He had been found wandering the streets and rubbing his nose. He was quite confused and disoriented, complaining of smelling burning odors and seeing large people and trucks in the emergency room. The patient could give no information on his activities for the last 3 hours.

Medical History

The patient denied any recent or past history of trauma, and there were no indications of trauma (bruises, swelling, or discoloration) on his head or body. No records of this individuals medical treatment were available and the patient could provide no additional information.

General Physical Examination

This was a young man of good physical condition who was confused and disoriented, with noticeable defects in memory. Because of his memory dysfunction, his correct age was not known until obtained at a later date from his last place of employment. His chest was clear to auscultation and palpation; the abdomen was soft, with no masses or tenderness. Lymph nodes were not palpable in axilla or groin. Blood pressure, pulse, temperature, and respirations were normal.

Neurologic Examination

Mental Status: At the time of admission the patient was cooperative, yet confused and disoriented with respect to time and place. He could not state his name or age but could describe and name the farm where he had last worked; otherwise he could supply only a few details of his past life. He had experienced periods of global amnesia during the past 24 hours and described numerous visual and olfactory hallucinations. He was able to follow two- and three-step commands accurately but could not repeat the commands by memory after a delay of 5 minutes. His speech and comprehension of language were appropriate; however, he was unable to read. He could recite the first 10 letters in the alphabet with one or two mistakes. He could write several words such as cat or dog and could copy words, but was unable to read what he had copied. He could do simple one- and two-digit calculations. He was unable to identify colors and could not provide the correct name for many common objects, such as door or window, but he could describe these objects and state their use.

Cranial Nerves: Optic discs were clear, with sharp borders; a pronounced deficit in the right visual field was present. Jaw-jerk and gag reflexes were normal, facial expressions were complete and symmetric, palate and uvula elevated symmetrically, and the tongue protruded on the midline.

Motor Systems: His motor system was intact throughout his body, with normal deep tendon reflexes and no loss of strength.

Sensory Exam: Pinprick, temperature, vibratory, and proprioceptive sensation were intact through his body and face.

Follow-up

The patient was admitted to the hospital for observation. After 24 hours tile visual and olfactory hallucinations decreased. Two days later he was discharged to a local community shelter for assistance. Examination two weeks later revealed that the defect in forming recent memories had cleared; however, he still could not recall events from 24 hours prior to his admission through the end of his first week of discharge. He was capable of supplying his name and some details from his life, but still could not recall his age. He could do simple arithmetic calculations. However, the alexia and a pronounced anomia for visual objects and colors were observed to persist.

 

QUESTIONS

  1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
  2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
  3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
  4. Are any changes in sensory functions detectable?
  5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
  6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
  7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
  8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
  9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?

 

 

Case Study 10- I

Chief Complaint

This is a 34-year-old, right-handed male with emotional instability and clumsiness is being evaluated for work-related, safety issues.

History of Chief Complaint

The patient is a laborer in a paper and pulp company who was referred to the company physician by his floor supervisor. The company had employed him, in good standing, for 16 years; however, recently his work habits and personality had undergone a progressive change. He had become extremely emotional, yelling at his fellow workers and making unusually rude and sexual comments to the office staff. He had also begun arriving late and frequently got confused on the job, leaving tasks unfinished. In addition, he had begun to move his hands and arms strangely. At first insidious, these random movements now interfered with his work. He appeared clumsy, frequently dropping tools and occasionally stumbling when walking. The supervisor suspected alcoholism and requested the physician's evaluation to determine if it was safe to have him remain at work around heavy industrial equipment.

Family History

At the time of first examination, he was living with his wife and two children, who were 15 and 16 years of age. His mother was alive and in good health. His father had died at age 38 in an accident at the paper company plant 18 years before but had been in good health until that time. The maternal and paternal grandparents were dead. The paternal grandfather had died at 43 years of age; he had not seen a physician but was described by the family as having gone "daffy" and died of the "shakes," which they had attributed to his excessive drinking.

Medical History

The patient had left public school at the age of 18 after completing the 10th grade and obtained a job at the paper company. He had not seen a physician previously, and the only records available were those of the grade school nurse, which were unremarkable. He admitted to a 25-pack-year history of smoking and to having consumed two to three (16 oz) cans of beer per day.

General Physical Examination

The patient was a well-nourished, well-hydrated, muscular adult male appearing the stated age, with poor hygiene. Head was normocephalic. Funduscopic examination revealed no evidence of exudate, hemorrhage, or papilledema. There was no cervical, supraclavicular, or inguinal lymphadenopathy. The thyroid was positioned on the midline without masses or nodules. He had a regular heart rate and rhythm without gallops or murmurs and carotid pulsations were clear. The lungs were clear to auscultation and percussion. The abdomen was soft, without masses, tenderness, rigidity, or rebound. Peripheral pulses were intact (+2/4) at the radial, femoral, popliteal, dorsales, and tibialis. There was no peripheral edema. Genitalia showed a circumcised penis with testes descended bilaterally. A soft, reducible mass was present in the right inguinal ring. Rectal examination showed sphincter tone intact without fissures, tags, or stenosis. Prostate was grade II without nodules or tenderness, and the stool was guiac negative.

Neurologic Examination

Mental Status: The patient was awake but seemed disoriented with respect to time and place. He was irritable and responded inconsistently to questions. He was able to add and subtract single-digit numbers but could not divide or multiply. He could follow most two-step commands but not three-step commands. Speech, comprehension, and memory were appropriate for his education.

Cranial Nerves: He had a full range of eye movements and complete visual fields. Pupils were equal and reactive to light, both direct and consensual. His hearing was normal in both ears. His facial expressions were full and symmetric. The corneal, jaw-jerk, and gag reflexes were intact. The palate elevated symmetrically and the tongue protruded on the midline. His shoulders elevated symmetrically.

Motor Systems: Strength was 5/5 in the upper and lower extremities; coordination appeared intact but was hard to assess because of the involuntary motion. Tone in the limbs appeared slack, when not in motion. Deep tendon reflexes were +2/4 symmetric in all limbs; however, tendon taps were pendular. A continuous writhing motion was present in his hands and arms. This consisted of jerky, quick motions about the wrist and slower, wandering motions in the arm. He could not stop these motions on command and frequently tried to hide the more obvious ones by combining the motion with other, more purposeful arm movements. He also had jerky movement in his feet and legs that interfered with his gait, causing him to lose balance occasionally and contributing to his drunken appearance. He denied the existence of the involuntary movements, claiming he was nervous about being in a doctor's office. His wife was not sure when the movements began, but claimed that he had been making them for at least 9 months. She also stated that he did not have any involuntary motion when asleep.

Sensory Exam: Cutaneous sensory functions were intact throughout the body; proprioception was intact in all limbs.

 

QUESTIONS

  1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
  2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
  3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
  4. Are any changes in sensory functions detectable?
  5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
  6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
  7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
  8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
  9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?

 

 

Case Study 10-2

Chief Complaint

A 67-year-old, right-handed, male who has personality changes and a tremor.

History of Chief Complaint

The patient is a retired city worker was brought to you by his wife because of "shaking" and "weakness." The wife reported that not only did his hands shake; but there had been changes in his personality. She also complained that he had become very slow or "weak" in his movements and often sat motionless with an expressionless face. He had difficulty getting up and moving about the house. She admitted that this had been going on for over a year and was getting worse, but she had resisted seeking treatment since she felt that he had just grown lazy after retirement. He had recently suffered several falls, one of which had resulted in a skin laceration on his forehead. She was seeking a physician at this time because he had started to make "funny noises with his mouth."

Medical History

Until now he had been in good health except for an appendectomy at age 18.

Family History

At the time of examination the patient had been retired for 2 years. He had three children, who were living independently; none had attended college.

General Physical Examination

This was an alert, cooperative, well hydrated, and well-nourished individual, oriented for place and time and appearing his stated age. He was seated quietly and did not offer much information during the examination, letting his wife provide most of the history. Optic discs were clear with sharp borders. Chest was clear to auscultation and percussion. Blood pressure was normal; peripheral pulses were intact; respirations and temperature were normal. Abdomen was soft to palpation, with no masses or tenderness present. Skin was of normal texture and turgor; a recent skin laceration, 2 cm in length, was present on his forehead.

Neurologic Examination

Mental Status: The patient was alert, oriented for time and place, and cooperative. Memory and knowledge were appropriate for his age. Speech was clear and meaningful, but soft and low in volume; his comprehension of language was good. He was capable of writing, but his letters were noticeably reduced in size when compared with a previous sample of 10 years ago provided by his wife.

Cranial Nerves: His range of movement for the extraocular eye muscles was full, and visual fields were complete to confrontation. The corneal, jaw-jerk, and gag reflexes were intact; palate and uvula elevated symmetrically; tongue protruded midline; and shoulder shrug was symmetric. A three-per-second resting tremor was present in the orofacial musculature that diminished on speaking and swallowing or when he opened his mouth. There was a detectable high-frequency hearing loss, more in the right ear than in the left.

Motor Systems: His strength was intact, and deep tendon reflexes were normal in all extremities. He had a three-per-second tremor in both upper and lower extremities that was ameliorated with movement and returned upon resting. There was cogwheel rigidity upon passive movement of the limbs. He had no dysmetria or past-pointing present in any extremity. With his arms extended, the tremor diminished and there was no pronator drift. The tremor returned when his arms were relaxed. His gait was slow, with many shuffling steps. Postural reflexes were compromised; if given an abrupt push, he retropulsed, with many short steps and was at risk for falling. The patient could not stand from a seated position in a low, soft-padded chair, but he could, after one or two attempts, rise from a higher chair with a stiffer seat.

Sensory Exam: Discrimiative touch and proprioception were intact throughout the body and face.

 

 

 

 

QUESTIONS

  1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
  2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
  3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
  4. Are any changes in sensory functions detectable?
  5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
  6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
  7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
  8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
  9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?

 

 

Case Study 10-3

Chief Complaint

This was a 54-year-old, right-handed female with a paralysis and subsequent uncontrolled movement.

History of Chief Complaint

The patient is a housewife who developed hemiparesis and hemiparesthesia of rapid onset in the right arm and leg 9 months earlier. Subsequently, the paresis and sensory deficit resolved over a 3-month interval; however, an involuntary, flinging motion of the right arm and a writhing, jerky motion of the right leg slowly developed during this time. She is in considerable distress, since the involuntary motions of her extremity disrupted her gait and postural station and thus incapacitated her in her daily routines. She admitted to severe social embarrassment because of the involuntary motion.

Medical History

Nine months previously, she had suffered a cerebrovascular event that left her with hemiparesis and hemibody sensory loss on the right side. Language and cognition were not noticeably affected in this event.

Social History

Her history is positive for hypertension, smoking, and alcohol consumption.

General Physical Examination

The patient was an alert, well-hydrated, but underweight female, appearing older then the stated age. Signs of exhaustion and distress were evident, and she was of anxious demeanor. Her optic discs were clear and had sharp borders; visual acuity was normal. Her neck was supple, with no bruits. Her blood pressure, heart rate, and respirations were slightly elevated. Her chest was clear to percussion, and the abdomen was soft, with no masses or tenderness. The remainder of the examination was precluded because of the excessive involuntary limb motion.

Neurologic Examination

Mental Status: This is an alert, oriented, and cooperative female in considerable emotional distress. Language, comprehension, reading, and memory were appropriate.

Cranial Nerve: Testing was complicated by the violence of her involuntary motion in the upper extremity. She had a full range of eye movements, pupils were equal and reactive to light, and accommodation was intact. The corneal and gag reflexes were intact; jaw-jerk was normotensive. Her hearing was equal in both ears. Her tongue protruded on the midline.

Motor Systems: Muscle strength and reflexes were normal in both extremities on the left but were difficult to test definitively on the right because of the continuous and violent involuntary motion. The movement in the upper extremity consisted of violent flinging motions superimposed on a continuous writhing jerky movement. The lower extremity demonstrated the continuous writhing motion with only brief jerks. Occasionally, the jerky motion in the lower extremity became violent. Attempts to reduce the motion in either extremity by physical restraint were unsuccessful. She could move the right extremities on command in between the involuntary motions. Gait was severely compromised by the flinging of the upper extremity. Although she did not experience an embarrassment of postural reflexes, the upper-extremity motion was continually pulling her off station. The involuntary movement of the right extremities was ameliorated with sleep but returned upon waking.

Sensory Exam: Vibratory sensation and pinprick were intact on the left; to the extent that it could be tested, both modalities were equivocal on the right.

 

 

QUESTIONS

  1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
  2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
  3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
  4. Are any changes in sensory functions detectable?
  5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
  6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
  7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
  8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
  9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?

 

 

Case Study 10-4

Chief Complaint

This was a 75-year-old, right-handed male with tonic posturing motions of the left upper extremity.

History of Chief Complaint

The patient suffered a cerebrovascular event two years previously. This event left him with a transient spastic paralysis of the left upper and lower extremities. The posturing movements developed subsequent to a resolution of the spastic paralysis. He is now presenting for an annual checkup, 2 years following a cerebrovascular event.

Social History

He was a Jewish scholar who emigrated from eastern Poland to the United States after the World War II.

Medical History

He had been in good health until 2 years before, when he suffered a cerebrovascular accident of rapid onset that left him with spastic paralysis and sensory paresthesia in the left extremities. At that time his strength in the left limbs was 2/5 and his. deep tendon reflexes were elevated at +4/4. No language or cognitive deficit was recorded at the time of the first presentation.

General Physical Examination

This was an alert, oriented, and cooperative man. He was well nourished and well hydrated and appeared his stated age. He had the male-pattern baldness. His optic discs were clear, with sharp borders. Visual acuity was normal with his glasses. His neck was supple; a slight bruit was present over the right carotid. His chest was clear to percussion and abdomen was soft to palpation, with no tenderness or masses. His heart rate, blood pressure, and respirations were physiologic. His peripheral pulses were intact at the wrists and ankles. His skin was warm and moist, with good turgor.

Neurologic Examination

Mental Status: He was alert, oriented for time and place, and cooperative. He gave precise history. Memory was appropriate; speech, writing, and reading (English, Polish, and Hebrew) were intact. He could list all the presidents in order and recite passages from the Torah verbatim.

Cranial Nerves: He had a full range of eye movements, and visual fields were intact. His hearing was significantly diminished, especially for the high frequencies, more so in the right ear than in the left. The corneal and jaw-jerk reflexes were intact; facial expression was symmetric and appropriate to the situation. The gag reflex was intact; palate, uvula, and tongue were symmetric in position. He had slightly diminished sensation to vibratory sense on the left side of his face.

Motor Systems: Strength was 5/5, and deep tendon reflexes were +2/4 for both extremities on the right. Strength was mildly reduced (4/5) for the upper limb on the left, and deep tendon reflexes were slightly elevated (+3/4). The lower limb on the left had reduced strength (3/5) and increased deep tendon reflexes (+3/4). An involuntary, posturing movement was present in the left limbs that had not been detected in his first presentation, poststroke. In the upper limb, the movement consisted of slow, writhing postural changes, including pronounced flexion of the wrist, and phatangeal-metacarpal joints. With the upper limbs held horizontally extended, the left limb wandered in position continuously. Occasional, sudden jerky movements of the upper limb occurred. The lower left limb displayed r, low postural movements that interfered with his gait. The movement disorder was somewhat masked by the more pronounced residual paralysis in the lower left limb. The involuntary motion ceased when the patient slept, returning when he awoke. Past-pointing and dysmetrla were not present on either side. Pronator drift did not appear to he present, but this was difficult to evaluate on the left side because of the wandering motion in the upper limb. With the upper limbs extended anteriorly and held in a fixed position, a 10-Hz tremor was present in the right arm, but not in the left. This movement in the right limb was ameliorated when the arm was relaxed to the adducted portion. The tremor could be seen in his writing, particularly if he held his hand off of the paper's surface as he wrote.

Sensory Exam: Response to pinprick, vibratory stimuli, and position sense was normal on the right side of his body and only slightly reduced on the left side.

QUESTIONS

  1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
  2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
  3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
  4. Are any changes in sensory functions detectable?
  5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
  6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
  7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
  8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
  9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?