DIAG 2740 Chapter 7 Case Studies

DIAG 2740 Chapter 7 Case Studies - Chapter 7 Case Studies...

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Chapter 7 Case Studies Case #1 Sudden Onset of Right Hand Numbness Chief Complaint An 81 year old right handed man came to the emergency room because of right arm numbness and mild language difficulty. History The patient had not seen a doctor in many years. Past medical history was notable for hypertension, diabetes, and angina. At 6:30 pm on the day of admission, he suddenly became confused and had difficulty combining words correctly into sentences. He also complained that he could not feel things with his right arm, and it felt numb. Furthermore, he had some difficulty using his right hand, saying he could not “grape with it.” Finally, he also had a vague blurring of vision that he could not explain in great detail. Physical Examination Vital signs: Temperature = 98.7º, Pulse = 60, BP = 169/79, Respiration = 12 Neck: no bruits Lungs: clear Heart: regular rate, no murmurs Abdomen: normal bowel sounds, soft, nontender Neurological exam: Mental status : alert and oriented x3. Speech fluent, but with occasional paraphrasic errors, substituting letters in words incorrectly (see history “graping with hand”). Good naming and repetition. No left-right confusion or finger agnosia. Was able to do simple calculations. Had difficulty reading and writing. Cranial nerves : pupils 2 mm, contracting to 1.5 mm in response to light. Poor cooperation on visual field testing, but seemed to have difficulty at times seeing the fingers on the right side. Extraoccular movements full. Facial sensation intact to light touch and pinprick. Symmetrical smile. Gag reflex present. Normal sternomastoid strength. Tongue midline Motor : mild right pronator drift. Normal tone. Muscle strength 5/5 Reflexes : brachioradialis and biceps 1+ bilaterally. All others grade 0. Normal plantar reflex Coordination : normal finger to nose and heel to shin test Gait : normal on limited testing Sensory : Intact light touch and pinprick sense. Decreased vibration sense in both toes. grapesthesia and stereognosis normal in left hand, but absent in right hand. Occasional extinction in the right hand 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 cause?
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Case #2 Sudden Onset of Right Face, Arm, and Leg Weakness Chief Complaint A 62 year old right handed woman came to the medical clinic because of two days of numbness on her right face, arm and leg.
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