Acute Neurology – Clinical Acute Neurology – Clinical VignettesVignettes

Ronald G. Wiley, MD, PhDRonald G. Wiley, MD, PhD

VA 873-7510VA 873-7510

““ronald.wiley@vanderbilt.eduronald.wiley@vanderbilt.edu””

General approachGeneral approach

Question/answer #1Question/answer #1: Is patient biologically : Is patient biologically sick? (vs behavioral issues) If so, how sick? (i.e. sick? (vs behavioral issues) If so, how sick? (i.e. critically or not so serious?) critically or not so serious?) Composite Composite opinion that requires clinical judgment.opinion that requires clinical judgment.Question/answer #2Question/answer #2: What part of nervous : What part of nervous system is malfunctioning? system is malfunctioning? Functional anatomyFunctional anatomy - based primarily on - based primarily on neurological exam. neurological exam. Exam is an exercise in localization - first, Exam is an exercise in localization - first, pathophysiology - second.pathophysiology - second.

Question/answer #3Question/answer #3: What is/are likely : What is/are likely etiology(s)? etiology(s)? PathophysiologyPathophysiology - based on all available - based on all available information (history, exam findings, lab), but information (history, exam findings, lab), but heavily dependent on history) heavily dependent on history) Critical issues include - precise symptoms, mode Critical issues include - precise symptoms, mode and time of onset of symptoms, evolution of and time of onset of symptoms, evolution of symptoms with time, associated symptoms with time, associated symptoms/events, effects (symptoms/events, effects (±±) of ) of activities/therapies on symptoms, concurrent activities/therapies on symptoms, concurrent conditions, medicationsconditions, medications

Reading: Posner,JB, Saper,CB, Schiff,N. and Reading: Posner,JB, Saper,CB, Schiff,N. and Plum,F. Plum,F. Diagnosis of Stupor and Coma, Diagnosis of Stupor and Coma, 20072007..

1. A 26 y/o woman, previously in excellent health, complained of the worst headache in her life which developed over a 2-3 hour period. This did not prevent her from her usual duties, but 8 hours later (at 2:00 am) she awoke with a severe headache, nausea, vomiting and rapidly became unresponsive.

V/S: B.P. 100/60; P 96, reg; RR 10, shallow; T 36.8o C

General medical exam is unremarkable.

Neuro: HIF (~mental status): unresponsive to verbal stimuli. Cranial Nerves - II. No response to threat; fundi-normal; pupils are 2mm and sluggishly reactive to

light. III, IV, VI: Full EOMs to the doll's head maneuver. V. Trace corneal response bilaterally. VII. No grimacing. Motor/Sensory; increased tone bilaterally; flexor posturing in upper extremities and

extensor posturing in the lower extremities to noxious stimuli bilaterally. Reflexes; 3+ bilaterally, unsustained ankle clonus; bilateral Babinski reflexes.

She rapidly becomes apneic, requires intubation; the right pupil dilates to 6mm with the left pupil 2mm and a left flaccid hemiplegia develops.

2. You are called to see a 58 y/o defrocked priest who has a past history of mental illness and alcohol abuse. His admission to the medical service had been precipitated by pulmonary complaints and he has been shown to have an adenocarcinoma of the lung for which radiotherapy has been started the previous day.

Over the previous 48 hours he had developed progressive clouding of consciousness.

V/S: BP 130/80; P 96; R 24; T 38o C. Neck supple.

HIF: Mildly stuporous, but easily aroused when he assumes a crossed-leg sitting position and scratches his head with either hand. Non-communicative save for an occasional "yes." No spontaneous speech. No visual fixation on examiner. Cranial Nerves -

Normal fundi. Oculocephalic responses full with an occasional superadded saccadic

movement. Oculovestibular responses-nystagmus. Corneal responses intact. No facial asymmetry.

Motor - Hypotonic. No focal weakness. Bilateral intermittent multifocal myoclonic twitching movements.

Symmetrical brisk DTRs. Plantar responses are extensor.

3. A 53 y/o woman is brought to the E.R. by her husband, having been found wandering about their apartment early that morning in a confused state. She has a past history of autoimmune thrombocytopenic purpura which had been treated by splenectomy 2 years ago. Current medication is prednisone 5 mg bid.

V/S: BP 120/80; P 90; R 18; T 38o C.

HIF: Neck supple. Fluctuating between lethargy and agitation. Only vocalization was moaning and grunting in response to verbal or tactile stimulation. CN: Fundi normal. Full eye movements. Blepharospasm. No facial asymmetry. Sensory - intact. Motor: Paratonic. No focal weakness. Symmetrical brisk DTRs. Plantar responses - bilateral extensor.

4. A 52 y/o black female is referred to the emergency room from her local HMO for acute onset of vertigo, gait unsteadiness, nausea and slurred speech. In the several hours since the symptoms began, she has also noted new onset of oscillopsia, tingling in her left hand and mild occipital headache. She has a history of hypertension treated with Aldoril, and 10 months earlier, she had an episode of nystagmus and horizontal diplopia. CT and LP at that time were WNL.

V/S: BP 150/120, afebrileWN, WD, BF in NAD.

Head and neck exam - benign.

HIF: WNL Coordination: Decomposition of movement with slow, irregular RAMs of left arm and leg. Cranial Nerves - Horizontal nystagmus to right in primary position which increased on right gaze

and decreased on left gaze. Rotatory component developed on vertical gaze. Full EOMs.

Decreased light touch in right V2 and V3 and decreased pin in V3 on left. Mildly increased palpebral fissure and lag to corner of mouth on left. Uvula deviated to right and patient was dysarthric for all speech sounds. Sensory: Decreased pin and light touch in hands, L & R. Rest of Exam: WNL except for unsteady gait.

5. You are called to Triage to see a 52 y/o white male farmer for confusion and double vision. He states that he has been feeling weak and is unable to walk. Wife reports that her husband became acutely confused approximately 3 days before. She also states that he slipped on a tractor the week before hitting his head; no LOC. He and his wife report an ETOH habit of two to three beers a night. No toxin exposure reported although he has recently finished spraying his tobacco with herbicide. He is on no meds.

V/S: BP - 100/70 without orthostatic change P-84 R-18 T-98o po

General exam - skin shows a macular hyperpigmented rash over the abdomen and anterior thorax.

HIF - Disoriented in all spheres. Memory - Recent & immediate recall impaired. Calculations - can make change. (R)-(L) orientation intact. (-) dysnomia/agnosia. Written constructions good; can read & write. Gait & Station - wide base; unable to tandem. Coordination - RAM somewhat slowed. Cranial Nerves - Bilateral 6th N. palsy (L) worse than (R). Nystagmus in all fields of gaze; none in primary position. Sensory - intact. Motor - Strength 5/5 all; atrophy 1st dorsal interosseous on right. DTRs - 2+ all except ankles = 0/0