CMED 311 [NEURO: PEDIA CORRELATES/PBL]

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

CASE 1 - Headache localized to bifrontal regions, 5-6/10

A. CASE - Paracetamol as needed for relief
- 2mo PTA, headaches occuring more frequently, took ibuprofen
 Chief Complaint: Headache
- 1mo PTA, increased severity and occurring daily. Consulted and
 General Data: 15 y/o female, right handed, from Malate, Manila
were advised to take amlodipine 5mg/day for BP Control. Still
 History
experienced intermittent headaches
- Headache localized in the left temporal area, spreads to entire
- 2 weeks PTA, occurring daily with severity of 8/10, unable to
head
work, right arm weak and unable to lift objects
 Throbbing, Pulsating or Sometimes Squeezing
- 3 days PTA, vomited assoc. with headache
 5-8/10
- 1 day PTA, woke up with severe headache and vomited twice,
- Feels Nauseated or vomits
with right facial droop
- Prefers to be in the dark and quiet room
 ROS
- Bright lights, strong smells , and loud noise make her headache
- Wears eye glasses
worse
 PMH
- Lasts several hours
- (+) HPN
- Takes Paracetamol which provides temporary relief
- 2 weeks PTC, around the time of her periodical exams, headaches  FMH
were occurring daily - (-) migraine (+) HPN
- staying up late and has been only getting 5-6 hours of sleep over  Personal/social
the last two weeks - Construction worker, cigarrette smoker 1/per day for 25 years
 ROS - Alcohol 1-2bots every weekend
- Wears eyeglasses for myopia - Denies drug use
 PMH  PE
- (+) Asthma – not on any medications - HR 76bpm | RR 20 | BP 100/60 | T 36.7 C | WT 60kg
- Well groomed, well-nourished, not in distress
 Family History
- HEENT, Chest and Lungs, CVS, Abdomen, Extremities: normal
- (-) Migraine
- Neurologic Examination:
- (+) Hypertension - Father
- Mental Status: Awake, Alert, Oriented to time, place and
 PE
person, answers appropriately, follows commands
- HR=90 BPM | RR=18 | BP=100/60 | T=36.4 C
 CNS:
- HEENT, Chest and Lungs, CVS, Abdomen, Extremities: Normal
- II-visual acuity 20/25 with correction CN VI is
- Neurologic Examination -
- III, IV, V- limited abduction both eyes compressed
 Mental Status: Awake, Alert, Oriented to time, place and
- VII- right facial droop, able to wrinkle forehead due to inc. ICP
person, answers appropriately, follows commands
- VIII-intact gross hearing
- Funduscopy: Sharp discs, no papilledema, no hemorrhages
- IX, X- normal swallowing and phonation, intact gag
- Motor: Normal muscle bulk and tone, strength 5/5 in all
- XI-good SCM tone and strength
extremities
- XII- tongue midline on protrusion
- DTRs: 2+ in upper and lower extremities, symmetric, (-)
Babinski  Funduscopy: (+)papilledema both eyes
- Gait: Normal  Motor:
- Normal muscle bulk B/L Lateral rectus weakness
- Cerebellars: No Ataxia, No dysmetria
- increased tone in RUE>RLE B/L papilledema (Inc. ICP)
- Sensory: Normal to light touch, temperature, vibration
- normal tone in LUE and LLE, R Facial droop
- Meningeals: No nuchal rigidity RUE>RLE Weakness and
- strength 4/5 in RUE
- 4+/5 in RLE spasticity
B. DISCUSSION + Babinski on the Right
 With no prior history of headache and localization pertains to no - 5/5 in LUE and LLE
anatomic location, we can consider this is a case of Primary  DTRs:
Headache. - 2+ in LUE and LLE,
 The physical examination and history are all normal also in the above - 3+ in RUE and RLE, Neuroblastoma multiforme
case. - (+) Babinski on the right
 The triggers for headache include stress, depression, anxiety,  Gait: drags right leg when walking
excitement and shock.  Cerebellars: No Ataxia, No dysmetria
 Primary Headache is different from Secondary headache in which the  Sensory: Normal to light touch, temperature, vibration
latter has underlying cause and is manifested by headache.  Meningeals: No nuchal rigidity

C. ANATOMICAL AND CLINICAL DIAGNOSIS B. DISCUSSION

 Primary Headache with trigeminal innervation of pain-producing  Chronic progressive headache due to an
intracranial structures. - increase in intracranial pressure
- to consider brain tumor
- space-occupying lesion
CASE 2
- a gradual process, hence CVA diagnosis can’t be made because
A. CASE
of its sudden/acute in nature.
 Chief Complaint: Headache
 General Data: 50 y/o male, Right handed, from Bacoor, Cavite
 History

*Legend: Additional notes – color RED “I can do all things through Christ who strengthens me”. Ph. 4:13 | Page 1 of 3
 CMED 311 [NEURO: PEDIA CORRELATES/PBL]

C. ANATOMICAL AND CLINICAL DIAGNOSIS - Right central facial palsy, the rest intact
 Anatomical Diagnosis:  Funduscopy:
- (Upper Motor Neurons) Left Frontal Cerebral Cortex Lesion and - Sharp disc, no papilledema, no hemorrhages
Right Hemiplegia  Motor:
- Normal muscle bulk and tone
 Clinical Diagnosis: - strength is 5/5 on the left
- (+) right facial droop but unable to wrinkle forehead - 2/5 on the UE
- (+) right arm weakness - 3/5 on the LE
- (+) Babinski on the right  DTRs:
- Gait: drags R Leg when walking - 2+ in left UE and LE
- Decreased Muscle strength in both RUE and RLE - 3+ in the right
- but had increased Deep Tendon Reflexes. - (+) Babinski right
- Normal Sensory function.
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
CASE 3  Clinical Dx: Right Hemiplegia with aphasia secondary to Left Middle
A. CASE Cerebral artery occlusion
 General Data: 65 years old, Female, right handed, from Malate Manila
 CHIEF COMPLAINT: inability to talk CASE 4
 HPI: A. CASE
- Two hours prior to consult, patient woke up with right-sided  21 year old truck driver had a motorcycle accident and was not able
weakness and inability to talk. She is apparently well the day to move his extremities.
before  BP 100/80 mmHg, PR 100/min, Regular, RR 24/min, Regular
 ROS:  PE: He was alert and oriented to three spheres
- She has intermittent headache and dizziness for the past  HEENT, Chest and Lungs, Cardiac, and Abdominal exam:
month but did not consult unremarkable
 PMH:  Extremities:
- (+) HPN but not compliant with her medications, no - Upper extremities are intact
hospitalizations and surgeries - Back and spine: +Hematoma over the thoraco-lumbar area.
 FMH: - Lower extremities: Complained of numbness and inability to lift
- (-) Migraine, (+) HPN –father, DM his legs and wiggle his toes.
 Personal-Social History:  Skin in the lower extremities is cold.
- She smokes 10 sticks of cigarette per day, market vendor  NE:
 PE: - MS intact, CN intact.
- Wt-75kg, Hr-90bpm, Rr-18, BP-180/100, Temp-36.4C, obese, - Motor: + complete paraplegia.
wheelchair borne, weak looking - Reflexes: ++ on both upper extremities Areflexia on the lower
 Extremities: extremities; (-) Babinski
- (+) paralysis of the right arm and leg  Sensory: Sensory level at T10 with almost negative sensation from
 Neuro Exam: T10 down,
- Mental Status: drowsy but able to follow simple commands,  Cerebellars and Meningeal signs: negative for abnormality
unable to speak
 CNs:

*Legend: Additional notes – color RED “I can do all things through Christ who strengthens me”. Ph. 4:13 | Page 2 of 3
 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 10th 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 10th edition

*Legend: Additional notes – color RED “I can do all things through Christ who strengthens me”. Ph. 4:13 | Page 3 of 3