Vignette SessionSession 5 - new

R. Wileywith L. Bederman

• 48yo RH WM with 6mo of fatigue and wt loss. He has had a 6wk of slurring his words, weakness in both arms and difficulty walking. He can’t do ADLs and has to use a wheelchair for the past week. Also, his L face and L arm are numb and tingling. No PMHx. FHx unremarkable. Married, smoker in the past, no drugs/etoh.

• General PE unremarkable, AFVSSNeurological exam: MS: awake, alert, and oriented with MMSE of 27/30. He could recall 1/3 objects and misspelled

while writing a sentence. Speech was mildly slurred; comprehension, repetition, and fluency were normal

CN: all wnl except OS 20/40 vision, and L sided facial droopMotor: mild general decrease bulk, esp. in the hands & feet. Tone - mildly increased with

“clasped knife” quality in all extremities, left > right. Strength - 4/5 all of LUE; RUE proximal 4/5, distal 4+/5; BLE 4+/5 proximally; distal LLE 4-/5, RLE 5/5

DTRs: jaw jerk brisk, 3+ BR, biceps, patellae on left, 2+ on right, hoffman and crossed adductor present bilat; no frontal release signs

Sensory: Impaired graphesthesia, stereognosis, with DSS extinction in the left hand. Light touch over the entire face was abnormal. Pin & touch perception was decreased on the left side of the body. Vibration was decreased in the toes; proprioception was normal in feet bilat.

Coordination: Finger-to-nose and heel-to-shin were done slowly, but not with prominent ataxia. Rapid alternating movements were slow in the left hand.

Gait: barely able to take a few steps, and only with support. His legs moved stiffly, exhibiting circumduction bilaterally, left more than right. Heel walking was more difficult than toe walking. Tandem - unable, Romberg - negative, but unable to balance while walking on his toes or his heels.

22 yo RH AAF presents to the ED being unable to walk. She is a live-in housekeeper and 1 week ago she fell on the stairs at her employer’s house and hurt her back. At that time, she was seen in the ED for low back pain, had a negative exam and x-rays. Four days ago, the pain spread up the back into the neck without radiation to other extremities. Today, she laid down and then could not get up or move her legs. No paresthesias or change in pain. No bowel or bladder problems. No meds, no SH/FH that is relevant.

Vitals: P 80 BP 120/80 R 16 T 37 Gen: tenderness C2-C4 and scapulae bilaterally

NeuroMotor – UE 5/5; LE appears 0/5 except for small spontaneous movements; later in exam held legs rigid when swung over the stretcher; moved foot a bit when asked to wiggle toes, later tone in UE and LE normalDTR – 2+ throughout, brisk abdominal and analSensory – T4 sensory level to pain, vibration and cold; sternum split by sensory level

75 yo WM w/ history of HTN, recently diagnosed bladder CA and massive AAA who presents with progressive paraparesis. This morning the patient experienced sudden onset of severe interscapular back pain which later subsided, but then he noted progressive lower extremity weakness R > L, inability to walk and urinary retention.

Vitals: P 90 BP 190/110 R 20 T 37Gen: prominent abdominal pulsation with increased width, bladder percussible to umbilicus

NeuroMotor – tone decreased in LE bilaterally; strength UE 5/5; RLE ileopsoas 0/5, others 3/5; LLE ileopsoas 3/5, others 4/5DTR – extensor plantar bilaterally, absent anal weak and abdominalSensory – sensory level to pain at T8 on R, T10 on L, decreased temp LE bilaterally L > R, vibration and proprioception intactGait – unable to walk

16 yo RH WF with no pmh c/o of diffuse weakness. Nine days ago, she complained of nasal congestion and temp of 101 F, followed by bilateral, throbbing eye pain. Five days ago, she developed shoulder and back pain, painful sensation in her legs, and bilateral lower extremity weakness. Since yesterday, the weakness has progressed, and today, her arms are also weak and her speech is slurred.

Vitals: P 94 BP 120/84 R 22 T 37.4 Gen: poor inspiration despite maximal effort without rales or rhonchi

NeuroCN – bilateral facial palsies, nasal voice, neck flexor 4/5Motor – hypotonic, strength: deltoids 2, triceps 3, biceps 4R/3L, interossei 4, psoas 0R/1L, distal LE 0DTR – 0 throughout, equivocal plantar responseSensory – decreased pain and vibration LE, decreased position LE and fingers

20 yo M w/ history of testicular CA who received cis-platinum chemo this morning now with sudden onset of jaw spasm. He had a few episodes of vomiting after chemo, but otherwise tolerated it well. This afternoon, his jaw suddenly and uncontrollably deviated to the right and remained locked in this position for several minutes. Twenty minutes later, his jaw suddenly deviated to the left and remained there for 1 min. Between episodes he complained of jaw pain, but no other neurological symptoms.

Vitals: P 80 BP 110/70 R 20 T 37 Gen: pale, chronically ill-appearing

NeuroSensory – decreased vibration in distal LEDTR – decreased ankle jerk bilaterally

10 minutes after you leave the room, his jaw suddenly deviates to the right and he is unable to open his mouth of move his chin to the left. This subsides 2 min later.