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CMED 311 [NEURO: PEDIA CORRELATES/PBL]
CMED 311
[NEURO: PEDIA CORRELATES/PBL]

Lecturer

Dr. Aida Salonga

Trans scriber/s

MC Manay

Lecturer Dr. Aida Salonga Trans scriber/s MC Manay Date Aug 14, 2018

Date

Aug 14, 2018

CASE 1

A.

CASE

 

Chief Complaint: Headache

General Data: 15 y/o female, right handed, from Malate, Manila

History

 

-

Headache localized in the left temporal area, spreads to entire head

 

Throbbing, Pulsating or Sometimes Squeezing

5-8/10

 

-

Feels Nauseated or vomits

-

Prefers to be in the dark and quiet room

-

Bright lights, strong smells , and loud noise make her headache worse

-

Lasts several hours

-

Takes Paracetamol which provides temporary relief

-

2 weeks PTC, around the time of her periodical exams, headaches were occurring daily

-

staying up late and has been only getting 5-6 hours of sleep over the last two weeks

ROS

-

Wears eyeglasses for myopia

PMH

-

(+) Asthma not on any medications

Family History

 

-

(-) Migraine

-

(+) Hypertension - Father

PE

-

HR=90 BPM | RR=18 | BP=100/60 | T=36.4 C

-

HEENT, Chest and Lungs, CVS, Abdomen, Extremities: Normal

-

Neurologic Examination -

 

Mental Status: Awake, Alert, Oriented to time, place and person, answers appropriately, follows commands

 

-

Funduscopy: Sharp discs, no papilledema, no hemorrhages

-

Motor: Normal muscle bulk and tone, strength 5/5 in all extremities

-

DTRs: 2+ in upper and lower extremities, symmetric, (-) Babinski

-

Gait: Normal

-

Cerebellars: No Ataxia, No dysmetria

-

Sensory: Normal to light touch, temperature, vibration

-

Meningeals: No nuchal rigidity

B.

DISCUSSION

 

With no prior history of headache and localization pertains to no anatomic location, we can consider this is a case of Primary Headache.

The physical examination and history are all normal also in the above case.

The triggers for headache include stress, depression, anxiety, excitement and shock.

Primary Headache is different from Secondary headache in which the latter has underlying cause and is manifested by headache.

C.

ANATOMICAL AND CLINICAL DIAGNOSIS

Primary Headache with trigeminal innervation of pain-producing intracranial structures.

 

CASE 2

A.

CASE

Chief Complaint: Headache

General Data: 50 y/o male, Right handed, from Bacoor, Cavite

History

 

*Legend: Additional notes color RED

 

-

Headache localized to bifrontal regions, 5-6/10

-

Paracetamol as needed for relief

-

2mo PTA, headaches occuring more frequently, took ibuprofen

-

1mo PTA, increased severity and occurring daily. Consulted and were advised to take amlodipine 5mg/day for BP Control. Still experienced intermittent headaches

-

2 weeks PTA, occurring daily with severity of 8/10, unable to work, right arm weak and unable to lift objects

-

3 days PTA, vomited assoc. with headache

-

1 day PTA, woke up with severe headache and vomited twice, with right facial droop

ROS

- Wears eye glasses

PMH

- (+) HPN

FMH

- (-) migraine (+) HPN

Personal/social

- Construction worker, cigarrette smoker 1/per day for 25 years

- Alcohol 1-2bots every weekend

- Denies drug use

PE

- HR 76bpm | RR 20 | BP 100/60 | T 36.7 C | WT 60kg

- Well groomed, well-nourished, not in distress

- HEENT, Chest and Lungs, CVS, Abdomen, Extremities: normal

- Neurologic Examination:

- Mental Status: Awake, Alert, Oriented to time, place and person, answers appropriately, follows commands

CNS:

- II-visual acuity 20/25 with correction

- III, IV, V- limited abduction both eyes

- VII- right facial droop, able to wrinkle forehead

- VIII-intact gross hearing

- IX, X- normal swallowing and phonation, intact gag

- XI-good SCM tone and strength

- XII- tongue midline on protrusion

Funduscopy: (+)papilledema both eyes

Motor:

- Normal muscle bulk

- increased tone in RUE>RLE

- normal tone in LUE and LLE,

-

strength 4/5 in RUE

-

4+/5 in RLE

-

5/5 in LUE and LLE

DTRs:

-

2+ in LUE and LLE,

-

3+ in RUE and RLE,

- (+) Babinski on the right

Gait: drags right leg when walking

Cerebellars: No Ataxia, No dysmetria

Sensory: Normal to light touch, temperature, vibration

Meningeals: No nuchal rigidity

B. DISCUSSION

Chronic progressive headache due to an

- increase in intracranial pressure

- to consider brain tumor

- space-occupying lesion

- a gradual process, hence CVA diagnosis can’t be made because of its sudden/acute in nature.

I can do all things through Christ who strengthens me”. Ph. 4:13

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CMED 311 [NEURO: PEDIA CORRELATES/PBL]
CMED 311
[NEURO: PEDIA CORRELATES/PBL]

C. ANATOMICAL AND CLINICAL DIAGNOSIS

Anatomical Diagnosis:

- (Upper Motor Neurons) Left Frontal Cerebral Cortex Lesion and Right Hemiplegia

Clinical Diagnosis:

- (+) right facial droop but unable to wrinkle forehead

- (+) right arm weakness

- (+) Babinski on the right

- Gait: drags R Leg when walking

- Decreased Muscle strength in both RUE and RLE

- but had increased Deep Tendon Reflexes.

- Normal Sensory function.

increased Deep Tendon Reflexes . - Normal Sensory function. CASE 3 A. CASE  General Data:

CASE 3

A.

CASE

General Data: 65 years old, Female, right handed, from Malate Manila

CHIEF COMPLAINT: inability to talk

HPI:

-

Two hours prior to consult, patient woke up with right-sided weakness and inability to talk. She is apparently well the day before

ROS:

-

She has intermittent headache and dizziness for the past month but did not consult

PMH:

(+) HPN but not compliant with her medications, no hospitalizations and surgeries FMH:

-

-

(-) Migraine, (+) HPN father, DM

Personal-Social History:

-

She smokes 10 sticks of cigarette per day, market vendor

PE:

-

Wt-75kg, Hr-90bpm, Rr-18, BP-180/100, Temp-36.4C, obese, wheelchair borne, weak looking

Extremities:

 

-

(+) paralysis of the right arm and leg

 

Neuro Exam:

 

-

Mental Status: drowsy but able to follow simple commands,

 

unable to speak

 

CNs:

*Legend: Additional notes color RED

- Right central facial palsy, the rest intact

Funduscopy:

 

-

Sharp disc, no papilledema, no hemorrhages

 

Motor:

 

- Normal muscle bulk and tone

 

- strength is 5/5 on the left

- 2/5 on the UE

 

- 3/5 on the LE

DTRs:

 
 

- 2+ in left UE and LE

 

- 3+ in the right

 

- (+) Babinski right

 

B.

DISCUSSION

 

Right-Sided Hemiplegia And Aphasia

 

-

lesion is in the upper motor neurons

 

corticospinal tract

 
 

-

voluntary movements of the hands and little on the

lower limbs

 

paralysis is on the right side which may be due to a lesion in the left part of the brain

-

- supplied by the Middle cerebral artery

 

- Broca’s area, which is responsible for speech, is

probably affected, located at the left posterior inferior frontal lobe in almost all of the right handed people

 

corticobulbar tract

 
 

-

controls the facial movements which may be

responsible for the right facial palsy seen in the patient.

Pertinent positives:

 

- patient is obese and is hypertensive non-compliant on medications

- a persistent increase in blood pressure that also leads to increase ICP

- damages one of the arteries in the brain in which in this case, could be the middle cerebral artery.

Localization: Motor cortex and broca’s area

 

C.

ANATOMICAL AND CLINICAL DIAGNOSIS

Anatomical Dx. Possible occlusion of the Left middle cerebral artery

Clinical Dx: Right Hemiplegia with aphasia secondary to Left Middle Cerebral artery occlusion

 

CASE 4

 

A.

CASE

21 year old truck driver had a motorcycle accident and was not able to move his extremities.

BP 100/80 mmHg, PR 100/min, Regular, RR 24/min, Regular

 

PE: He was alert and oriented to three spheres

 

HEENT,

Chest

and

Lungs,

Cardiac,

and

Abdominal

exam:

unremarkable

 

Extremities:

 

- Upper extremities are intact

 

- Back and spine: +Hematoma over the thoraco-lumbar area.

- Lower extremities: Complained of numbness and inability to lift his legs and wiggle his toes.

Skin in the lower extremities is cold.

 

NE:

-

MS intact, CN intact.

 

-

Motor: + complete paraplegia.

 

-

Reflexes: ++ on both upper extremities Areflexia on the lower extremities; (-) Babinski

Sensory: Sensory level at T10 with almost negative sensation from T10 down,

Cerebellars and Meningeal signs: negative for abnormality

 

I can do all things through Christ who strengthens me”. Ph. 4:13

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CMED 311 [NEURO: PEDIA CORRELATES/PBL]
CMED 311
[NEURO: PEDIA CORRELATES/PBL]

Autonomic: distended bladder but with no sensation. Cold skin over the lower extremities.

B.

DISCUSSION

 

Paralysis of both lower extremities occur with diseases of the

- spinal cord,

- nerve roots,

- peripheral nerves.

If the onset is acute, difficult to distinguish spinal from neuropathic paralysis

-

because of the element of spinal shock, which results in flaccidity and abolition of reflexes.

Acute spinal cord diseases with involvement of corticospinal tracts

- paralysis or weakness affects all muscles below a given level;

- if the white matter is extensively damaged:

- sensory loss below a circumferential level on the trunk is conjoined

- (loss of pain and temperature sense because of spinothalamic tract damage, and loss of vibratory and position sense from posterior column involvement).

Bilateral disease of the spinal cord

- bladder and bowel and their sphincters are usually affected.

- result of an intrinsic lesion of the cord or an extrinsic mass that narrows the spinal canal and compresses the cord.

- spinal cord trauma

 

The most common cause of acute paraplegia (or quadriplegia if the cervical cord is involved) is,

usually associated with fracture-dislocation of the spine. (Adam and Victor’s Principles of Neurology 10 th edition)

(+) Hematoma of the thoracolumbar spine

 

-

possible that the paraplegia of the patient is caused by a spinal cord trauma since he had been in an accident.

Response in reflex is the diminished

 

- location of the lesion may be involving the lower motor neuron in the level of T10 which has almost negative sensation

- involving the bladder (distended) and skin (cold).

Sensory level- is the dermatomal level where there is decrease sensation. Upper two levels should be viewed with imaging to be sure of the location of the lesion.

C.

ANATOMIC AND CLINICAL DIAGNOSIS:

Spinal cord injury at the level of T10

Thoracolumbar hematoma affecting both legs resulting to complete paralysis, areflexia, of lower extremities

Distended bladder

No sensation secondary to MVA (motor vehicle accident)

REFERENCES:

1. Adam and Victor’s Principles of Neurology 10 th edition

*Legend: Additional notes color RED

I can do all things through Christ who strengthens me”. Ph. 4:13

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