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DIAG 2740 Chapter 10 Case Studies

DIAG 2740 Chapter 10 Case Studies - Chapter 10 Cases Case#1...

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Chapter 10 Cases Case #1 Sudden Onset Worst Headache of Life Minicase A 68 year old man suddenly developed “ the worst headache of my life.” He had a history of severe, diffuse, atherosclerosis, including coronary artery disease and vascular disease requiring multiple bypass operations. On the morning of admission, he was walking in a hallway at home, and at 10:00 he suddenly developed an explosive headache worse than anything he had ever experienced. The headache began in the bifrontal area and over the next few minutes spread all over his head and down his neck. He denied nausea, vomiting, loss of consciousness, or vision changes. Examination was unremarkable except for mild nuchal rigidity. Localization and differential diagnosis 1. What diagnosis should be suspected in case with this kind of clinical presentation? 2. What is the most common cause of this disorder, and what vessels are most commonly affected? 3. What kind of stroke is most likely in this patient? Case #2 Left Leg Weakness and Left Alien Hand Syndrome Chief Complaint A 67 year old woman suddenly developed left leg weakness and difficulty using her left hand. History Past history was notable for hypertension, peripheral vascular disease, and smoking one pack per day for 40 years. On the morning of admission, after finishing breakfast, the patient tried to stand up and suddenly found she could not support her own weight. She fell against a door, scraping her left side, but managed to reach a telephone and call an ambulance. Physical examination Vital signs: Temperature = 98º Pulse = 76 BP = 140/90 Respiration = 14 Neck: supple with no bruits Lungs: clear Heart: regular rate Abdomen: soft Extremities: a few abrasions on the left arm and leg
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Neurologic exam: Mental status : alert and oriented x3. The patient seemed unaware at times of any weakness on her left side and did not complain about her abrasions. Language was fluent. Cranial nerves : normal, except for a minimally decreased left nasolabial fold and mild dysarthria. Motor : Strength 5/5 throughout, except for 1/5 to 2/5 strength in the left leg, both proximally and distally, and 4/5 strength in the proximal left arm. Reflexes : all arm 3+, right patellar 2+, left patellar 3+, absent Achilles reflexes, left (+) Babinski. Coordination and gait : not tested Sensory : there was inconsistent decreased response to pin prick on the left side. Clinical Course The patient’s weakness temporarily worsened, so that by 2 days after admission she had 0/5 strength in both the left leg and arm. She also had extinction on the left side to double simultaneous tactile stimulation. One month later the patient had recovered 3/5 strength in the left arm but continued to have 0/5 strength in the left leg. Interestingly, she felt that her left arm was was “out of control.” Her left arm would occasionally grab onto things without her being aware of it, and she then had to use her right hand to release its grasp. She could not localize her left arm in space and had difficulty using it to perform voluntary activities, with marked motor impersistence.
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