vignettes #8

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Vignettes #8 Ronald G. Wiley, MD, P hD ronald.wiley@vanderbil t.edu Christopher Lee, MD, MS

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Vignettes #8. Ronald G. Wiley, MD, PhD [email protected] Christopher Lee, MD, MS [email protected]. - PowerPoint PPT Presentation

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Page 1: Vignettes #8

Vignettes #8

Ronald G. Wiley, MD, [email protected]

Christopher Lee, MD, [email protected]

Page 2: Vignettes #8

• HPI: 28yo RH AAF with Hx of schizophrenia on risperidone presents to the ED for altered mental status 1 day after discharge from an outside hospital where she had recent abdominal surgery and a prolonged hospital course complicated by sepsis treated with antibiotics. During that hospitalization she also had ICU delirium with agitation/psychosis - treated with large doses of haloperidol.

• PMHx, Fam Hx and Soc Hx otherwise non-contributory

• Vitals/general exam: 162/93, pulse 112, RR 16 temp 38.4°C. Diaphoretic and drooling.

General exam otherwise unremarkable, abdominal incision appears to be healing well

• Neurological Exam:

MS: not oriented to time, unable to repeat digits, anxious, dysarthric

Gait: unable to ambulate

Coordination: All movements slowed; bilateral dysmetria on FNF.

CN: intact cranial nerves II-XII

Sensory: unremarkable but unreliable due to AMS

Motor: diffusely increased tone - rigid in BLEs; cogwheeling present in BUEs; minimally decreased motor strength diffusely (4/5 in all extremities); fine bilateral hand tremor at rest

Reflexes: symmetric in all extremities (2+), no clonus, toes downgoing

Page 3: Vignettes #8

HPI: 52 yo F with history of HTN, presents to the ED with unsteady gait. During the past week, she has been intermittently dizzy. 2 days ago, she began having double vision on right gaze only. Yesterday, she had tingling in her right hand with some slurred speech. Today, she awoke with right-sided numbness and was very unsteady on her feet.

Vitals: P 62 BP 140/78 R 16 T 36°C Gen: lethargic, mildly rigid neck, otherwise unremarkable

Neurological ExamMS – lethargic, but arousable (pain, loud name calling), complains of mild HA,

mild dysarthriaGait – unable to walkCoord – moderate dysmetria on FNF and HKS with L > RCN – mild L ptosis, conjugate L gaze palsy, nystagmus on R and L gaze, diminished

R corneal response, decrease pain and light touch on R face, jaw deviates L, L peripheral facial paresis

Sensory – decreased pain and temp on RMotor – diffusely weak with decreased toneReflexes – diffusely hyper-reflexic, bilateral extensor plantar responses

Page 4: Vignettes #8

HPI: 76 yo RH WM, previously healthy, c/o acute onset of hoarseness, dysphagia, severe vertigo to where he could not stand or walk 7d ago. Sx unchanged since that time. Several days prior to the event, he suffered from intractable hiccoughs. FHx, SHx: noncontributory. No medical problems that he knows of prior to this but does admit that he did not visit the doctor much for 30yrs. No meds.

Vitals: P 120 BP 100/60 R 20 w/ hiccoughs T 37°CGen: HEENT - anhydrosis on L side, c/o dry eye (OS); o/w gen exam is wnl

Neurological examMS – lethargic, dysarthricGait: could not walk due to balance/coordinationCoord – slightly dysmetric FNF and HKS, clumsy RAM on LCN – lid ptosis on L, decreased pain and temp on L, decreased corneal reflex on L, decreased taste on L, decreased hearing on L, uvula deviates R, diminished gag on LeftSensory – decreased pain and temp on entire R half of bodyMotor: strength intact, but somewhat difficult to testReflexes: 1+ throughout, downgoing toes

Page 5: Vignettes #8

HPI: 40 yo RH WM, with no PMHx, complains of progressive Left-sided numbness, leg weakness and difficulty urinating. One year ago, he developed numbness + weakness in his Right hand, associated with tightness in the back of his neck. EMG at that time was unremarkable. 2 weeks ago, he underwent neck manipulation by a chiropractor -> his gait became rapidly more unsteady. He lost his ability to button clothes and developed numbness over the Left side of his body. FHx and SHx: are noncontributory, and he’s not on any meds.

Vitals: P 94 BP 120/84 R 18 T 37°C Gen: mild limitation in flexion and rotation of neck

Neurological ExamMS – intact in detailGait – circumducts L footCoord – mild tremor and slight dysmetria on FNF, HKS, RAMCN – moderate wasting of L sternocleidomastoid and upper trapezius, L tongue

moderately atrophicSensory – decreased pain and temp from C2 down on R and from C5 down on left,

position and vibration intactMotor – hypertonic L > R, 4/5 quadriparesis L > RReflexes – diffusely hyper-reflexic with clonus on L, bilateral extensor plantar,

abdominal reflex absent, anal wink present

Page 6: Vignettes #8

56 yo LH AAM w/ admitted earlier today with left calf swelling, pleuritic chest pain and dyspnea now with altered mental status. Lung scan showed moderate probability pulmonary embolus. After the scan, he was noted to be confused with a temp of 38. Patient reports losing the ability to read 2 days ago. He complains of numbness of fingers on the right, but pointed to his toes when asked to outline the region of numbness.

Vitals: P 100 BP 150/80 R 24 T 38.3 Gen: obese, Cushingoid, multiple spider angiomata, chest splinting on left w/ decreased breath sounds, LLE swollen and erythematous

NeuroMS – oriented to place and month, recalled year w/ difficulty; speech circumlocutory w/ word-finding errors and substitutions; mild dysnomia; 1/3 recall at 5 min; poor attention; unable to calculate or read; could draw clock and write name; unable to ID fingers or body parts, R/L confusionCN – R homonymous hemianopsiaSensory – decreased stereognosis and graphesthesia in R hand; decreased vibration and proprioception in feetCoord – slightly slowed RAM on R

Page 7: Vignettes #8

The End

Congratulations and

Good Luck – Keep Learning