DIAG 2740 Chapter 14 Case Studies

DIAG 2740 Chapter 14 Case Studies - Chapter 14 Cases Case#1...

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Chapter 14 Cases Case #1 Face and Contralateral Body Numbness, Hoarseness, Horner’s Syndrome, and Ataxia Chief Complaint A 22 year old woman suddenly developed left posterior neck pain, vertigo, ataxia, left facial numbness, and hoarseness after a chiropractic cervical adjustment. History The patient had been well until 4 months previously, when she injured her neck in a car accident. She saw a chiropractor daily for neck pain. On the day of admission, after her neck was “snapped” she suddenly felt increased pain in the left posterior neck region. As she left the chiropractor’s office, she felt dizzy and nauseated, and staggered out to her car falling toward the left. She noticed her vision bouncing or swaying (oscillopsia) but had no diplopia. She vomited twice, and when she reached home, her husband noticed that her voice sounded hoarse. She also felt numbness and tingling on the left side of her face. The symptoms did not improve after a brief nap, so she came to emergency room. Physical examination Vital signs: Temperature = 96º Pulse = 60 BP = 126/84 Neck: no bruits Lungs: clear Heart: regular rate, no murmurs or gallops Abdomen: soft, nontender Extremities: normal Neurologic exam: Mental status : alert and oriented x3. Normal language. Named months forward and backward with no errors. Recalled 3/3 words after 4 minutes. Cranial nerves : left pupil 2.5 mm constricting to 2 mm. Right pupil 3.5 mm constricting to 2 mm. Visual fields full. Right-beating horizontal and counterclockwise rotary nystagmus, which improved with rightward gaze. Patient reported an association perception of the visual field moving back and forth (oscillopsia). Extraocular movements full. Left ptosis. Decreased pin prick and temperature sensation in left opthalmic, maxillary, and mandibular divisions. Decreased left corneal reflex. Face symmetrical. Taste not tested. Hearing intact. Voice hoarse. Decreased palate elevation on the left, and decreased left gag reflex. Normal SCM strength. Tongue midline. Motor : no drift. Normal tone. Strength 5/5 throughout. Reflexes : all within normal limits.
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Coordination : mild ataxia on finger nose testing on the left. Toe tapping on the left was irregular in rhythm (dysrhythmic) Gait : unstable because of severe dizziness Sensory : decreased pin prick and temperature sensation in the right limbs and trunk below the neck. Intact light touch, vibration, and joint position sense. Localization and differential diagnosis 1. On the basis of the signs and symptoms shown in bold above, where is the lesion? 2. Given the sudden onset of deficits and neck pain and the distribution, which syndrome is described? Case #2 Hemiparesis Sparing the Face Minicase A 53 year old man with a history of cigarette smoking and hypercholesterolemia was driving home from the airport at 7:00 am one morning and had a 1 hour episode of pins and needles in his right perioral area, arm, and leg. He reached home, and at 10:00 am, while he was walking the dog, these symptoms
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DIAG 2740 Chapter 14 Case Studies - Chapter 14 Cases Case#1...

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