DIAG 2740 Chapter 6 Case Studies

DIAG 2740 Chapter 6 Case Studies - Chapter 6 Case Studies...

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Chapter 6 Case Studies Case #1 Sudden Onset of Right Hand Weakness Chief Complaint A 64 year old man developed right hand weakness following a cardiac arrest History The patient had a history of hypertension and cigarette use but was otherwise healthy until the day of admission, when he suddenly collapsed in church. Family members at the scene administered immediate CPR, and when the ambulance arrived, the patient received electrical defibrillation and promptly regained normal cardiac rhythm. He was admitted to the cardiac intensive care unit and was found to have episodes of rapid atrial fibrillation. Several days after admission he was noted to have weakness and spasticity of the right hand, and a neurologic consult was requested. Physical Examination Vital signs: Temperature = 98º, Pulse = 100, BP = 130/60, Respiration = 18 Neck: supple with no bruits Lungs: clear Heart: Irregular rhythm, with a soft systolic murmur Abdomen: normal bowel sounds, soft, nontender Extremities: normal Neurological exam: Mental status : alert and oriented x3. Language fluent, with intact naming, repetition, and reading. Able to recall 3/3 objects after 5 minutes. Cranial nerves: normal, including no facial weakness Motor : muscle strength 5/5 throughout, except right hand and wrist. Right wrist flexion, extension, and hand grip 3/5. Right finger extension, abduction, adduction, and thumb opposition 0/5. Reflexes : all grade 2 with normal plantar reflex Coordination and gait : not tested Sensory : intact light touch, pinprick, joint position, and vibration sense. No extinction on double simultaneous stimulation. Localization and differential diagnosis 1. On the basis of the symptoms and signs shown in bold above, where is the lesion? 2. Given the relatively acute onset of the deficits, and the presence of atrial fibrillation, what is the most likely diagnosis? Case #2 Sudden Onset of Left Foot Weakness Chief Complaint An 81 year old woman presented to the emergency room with left foot weakness. History The patient was previously healthy except for a history of hypertension and diabetes. On the morning of admission, as she got out of bed she noticed difficulty when she first put her foot on the floor. As she tried to walk she felt that she was dragging her left foot. Nevertheless, she continued her usual morning activities, using a chair for support. Later that morning, when the gait difficulty persisted, she called her children, who brought her to the emergency room. She had no other complaints except for a mild right frontal headache.
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Physical exam Vital signs: not recorded on admission Neck: supple with no bruits Lungs: clear Heart: regular rate, with soft systolic murmur Abdomen: benign, with normal bowel sounds Extremities: normal Neurologic exam: Mental status : alert and oriented x3. Speech fluent with intact naming and comprehension Cranial nerves : normal, including no facial, weakness Motor : no pronator drift. Normal tone. Strength 5/5 throughout except for the left foot and leg. Left ilopsoas and hamstrings 4/5, left ankle dorsiflexion and extensor hallucis longus 4/5.
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