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Neurology PBL

Podd PBL 1 2013 Spring

Joanna Tao

on 1 February 2014

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Transcript of Neurology PBL

Amyotrophic Lateral Sclerosis
Neurology PBL
Patient Information

Date: January 9, 2013
Time: 12:00 pm

Name: D.P
Source: Patient
Gender: Female
Age: 38 yo
Race: Caucasian
Reliability: Good
Chief Complaint

“I have a headache” x several months
History of Present Illness

38 year old Caucasian female, presents to the primary care complaining of
headaches confined to the right parietal area for several months
The headache is exacerbated by coughing and sneezing
quality of the headache is pressure-like
and presents with an increased
severity from 1/10 previously to a 5/10 today.

The headache is continuously
sporadic throughout the day and awakens her from sleep
Pt. has taken
Tylenol (500 mg) and Excedrin

but has not helped with the headache. Pt has experienced
for several months as well.
History of Present Illness

Pt has experienced
spasticity in her right arm as she was brushing her teeth yesterday morning which lasted for about 3 minutes.

Upon falling, she banged her wrist on the sink.
The muscle jerking tends to interrupt the patient’s sleep. Pt. mentions weakness on her right side of her body.
However, the pt. denies any tingling, numbness, and paralysis.
History of Present Illness

Last night her husband found her
confused and crying

for thirty minutes. Pt. states that she was semi-aware during this event. This morning her husband claimed she had
difficulty finding words.
Her husband has also noticed a
personality change
and states that she went from being
cheerful, funny, and smart to worried, irritable, angry, and forgetful
Pt’s. husband notices that she cries much more frequently.

Pt also has taken a medical leave from work due to these personality changes that causes her family and friends to avoid her.

Pt states she has been

vomiting for the last 2 months
which occurs 3-4 times sporadically throughout the day. Pt states the vomit contains food particles, denies blood, and nothing makes it better or worse.

»Pt denies any history of alcohol/illicit drug abuse and smoking
History of Present Illness
Most Likely Diagnosis
Frontal Lobe- associated with reasoning, planning, parts of speech, movement, emotions, and problem solving, Houses the Broca's area
Parietal Lobe- associated with movement, orientation, recognition, perception of stimuli
Occipital Lobe- associated with visual processing
Temporal Lobe- associated with perception and recognition of auditory stimuli, memory, and speech, houses the Wernicke's area
Based on the HPI, symptoms and physical exam, our patient most likely has a cerebral tumor, affecting the frontal or parietal lobe .The cerebrum controls and integrates motor, sensory, and higher mental functions, such as thought, reason, emotion, and memory. Each hemisphere is divided into four lobes:
Classification of Brain Tumors
Brain tumors are classified as

Primary Brain Tumors have their origins within brain tissue.
They are further classified by the type of tissue from which they arise and their location. For example
A tumor of the pituitary gland is called a pituitary adenoma
are tumors from the covering of the brain (meninges)
are tumors of the nerves entering the brain
arise from glial cells that surround and support neurons, Glial cells include the myelin producing oligodendrocytes and Schwann cells

are most common

Secondary Brain Tumors are caused by tumors of another cancer which metastasize to the brain.
Brain metastases are three times more common than all primary brain tumors combined and
are diagnosed in approximately 150,000 people each year.
–35% - lung
–20% - breast
–10% - kidney
–5% - gastrointestinal tract
Diagnostic work up does not solely rely on laboratory tests since there is no established tumor marker.Neuroimaging is relied upon to make the diagnosis.

Diagnostics test options include:

Cranial MRI- DOC for Brain Tumors
, gadolinium contrast is administered to enhance malignant tumors
CT scan with and without contrast- safe if patient has a contraindication to MRI such as a pacemaker or surgical clips
Positron emission tomography (PET) is useful in determining the metabolic activity of the lesions seen on MRI
Brain Biopsy- very invasive but provides definitive diagnosis
Serum Hormone levels
CBC with diff.
Electrolytes, Hemoglobin, Hematocrit.

The following are of use but rarely administered:
Cerebral angiogram
Electroencephalogram (EEG)
Lumbar puncture

If the MRI or CT scan suggest a brain tumor a brain biopsy will be the next step. This procedure is invasive and will require the patient to stay in the hospital for two to three days. Researchers from the University of Central Lancashire in the UK have recently published interesting findings in the journal Analytical and Bioanalytical Chemistry. T
hrough the analysis of 49 blood samples from patients with brain cancer and 25 from patients without it researchers have discovered the presence of a glioma
serum marker. The serum marker was discovered by the use of infrared lighting and protein biomarkers
. Similar to a PET scan,
the infrared lighting can also asses molecular vibrations which can give us an idea of whether or not the tumor is benign and malignant. The researchers say this whole process takes thirty minutes and is a cheaper alternative test.
Is There An Emerging Tumor Marker?
Tumor Grading
Microscopic Appearance
Growth Rate
WHO Grading
GX: Grade cannot be assessed (undetermined)
G1: Well-differentiated (Low-grade)
G2: Moderately Differentiated (Intermediate grade)
G3: Poorly Differentiated (High Grade)
G4: Undifferentiated (High Grade)
A combination of definitive and symptomatic treatments will eradicate brain tumors. Definitive treatment is dependent on the size, location & type of tumor:
Surgical excision

- indicated for: meningiomas, pituitary adenomas, schwannomas
Radiation therapy
-before surgery - to shrink mass size operating on and after surgery if tumors that are NOT completely resected- prolongs survival
with Temozolomide-75 mg/m2 daily by intravenous infusion over 90 minutes for 42 days concomitant with focal radiotherapy
Symptomatic treatments are not dependent on tumor type and are aimed at bettering
neurological disabilities created by the increased ICP. These treatments include:
- reduce edema and thus ICP
is DOC, "taper"initial 10 mg IV once, followed by 4 mg IM every 6 hours until symptoms of cerebral edema subside
0.5 mg X 2 daily (divided dose) to reduce swelling
2 mg - given before and after surgery + radiotherapy
- for patients with seizures, do not use as prophylaxis,
Levetiracetam- 1000 mg orally once daily
Topiramate- 200mg titrated over the course of the day in increments of 25
- prophylaxis for patients who are unable to walk, use inferior vena cava filters for patients with contraindications to anticoagulants such as those who have had craniotomy (risk of post op bleeding)
to lower ICP as needed- 0.25g/kg as a 15 to 20% solution IV over at least 30 min administered 8 hrs.
Treatment Options
, Drowsiness, Eventual Coma,
Decreasing responsiveness
, Slow thought processes,
Decreased movement/sensation
speech (aphasia)
Language difficulties
Loss of coordination/muscle function
(typically on one side), Seizures, Stiff neck, Vision changes,
Streptococcus spp. (S. intermedius ) – sinusitis

S. Aureus

Anaerobes – chronic otitis media/chronic pulmonary disease; polymicrobrial

From Mass Effect –

Most Common
same side

Change in Mental Status

Nuchal Rigidity

Lab Results
CT scan -> focal, low-density mass with peripheral enhancement & variable degree surrounding edema
MRI -> more sensitive/specific dx/follow up lesions + detects cerebritis/satellite lesions/inflammation spread -> ventricles/subarachnoid space
Conventional contrast-enhanced MRI ->

ring enhancement/ similar to necrotic high grade glioma
Needle Aspiration/Surgical Excision =
Elevated ESR, CRP; CBC with differential (leukocytosis/ shift to LEFT)
DDx: Brain Abscess
General- Pituitary tumors are defined as the abnormal growth of the pituitary gland. The pituitary helps control the release of hormones from other endocrine glands, such as the thyroid and adrenal glands. Examples of some of these hormones :ACTH, GH, Prolactin, TSH, LH, FSH
As the tumor progresses hypopituitarism will ensue due to damage of hormone releasing cells.
Symptoms- These symptoms are caused by the enlargement of the tumor



Nausea and vomiting
•Problems with the sense of smell- Pressure on the olfactory Groove and sella turcica, where the pituitary gland is situated

Visual disturbances
-Bitemporal hemianopsia as a result of pressure at the mid optic chiasm
Pituitary Adenoma
Endocrine function tests include:
•Dexamethasone suppression test
•Follicle-stimulating hormone (FSH) levels
•Insulin growth factor-1 (IGF-1) levels
•Luteinizing hormone (LH) levels
•Serum prolactin levels
•Testosterone levels
•Thyroid hormone levels
MRI of head, CT with contrast

Pituitary Adenoma Continued
: Inherited autosomal dominant disorder affecting chromosome 4 – CAG leads to a loss of GABA-producing neurons in the striatum. Usual onset
between 30 and 50 years
of age.

—involving the face, head and neck, tongue, trunk, and
Altered behavior

personality changes, antisocial behavior
depression, obsessive-compulsive features, and/or psychosis
Impaired mentation

Progressive dementia
is a key feature; 90% of patients are demented before age 50 years.
Gait is unsteady and irregular. Ultimately bradykinesia and rigidity prevail.
Speech Impairment

Diagnostic Lab Results:

Head MRI scan shows atrophy of head of caudate nuclei
–Genetic DNA test confirms diagnosis
Huntington’s Disease
- Progression
• Tripping, stumbling, or awkwardness when running
• Foot drop – “slapping” gait

• finger dexterity, cramping, stiffness, and weakness/wasting of intrinsic hand muscles
• Wrist drop

Slurred speech, hoarseness, or volume of speech

• Drooling
Etiology: MC neuromuscular degenerative disease affecting different ages and M>F, Increase risk factors could be pesticides/insecticides, exposure, smoking; multiple factors contribute to the cause of sporadic ALS, familial ALS is an inheritable selective motor neuron disease involving both corticospinal & lower motor neurons indistinguishable from sporadic
S/S: onset is subtle and symptoms are overlooked
–Initial symptoms:

Asymmetric Muscle Weakness

Tight and stiff muscles: spasticity
–Bulbar function:

Exaggerated motor expressions of emotion
Involuntary weeping or laughing
•Movements of face & tongue
•Maladaptive social behavior
Diagnostic Lab Results:

MRI/CT with myelography– R/O pressure, lesions on spinal cord and brain or any other neurological conditions
–EMG/NCV - measures the conduction of muscles
–CBC with Differential, thyroid assessment, vitamin deficiency, autoimmune disease
Like many other ailments, Brain tumors present with a variety of symptoms.

Symptoms are categorized as general and focal, patients will present to you with a combination of both.

General symptoms are nonspecific and include the following:


Cognitive deficiencies

Change in personality

Gait disorder

Nausea and
- controlled by the area postrema which is located within the medulla oblongata of the brain stem

Headaches are often the chief complaint of these patients.
The pain has no distinguishing features to link them to brain tumors. It is sporadic, of dull quality and moderate intensity. It is important to keep in mind that these
headaches are usually made worse by exertion or change in position, as is common with coughing and sneezing
These headaches are also associated with vomiting and nausea.

The causes of general symptoms is increased intracranial pressure or compression of CSF by the growing tumor and surrounding edema.
Clinical Features

Pertinent Negatives

Amyotrophic Lateral Sclerosis
Brain imaging is recommended within 24 hours of symptom onset. Although magnetic resonance imaging (MRI) with diffusion-weighted imaging (DWI) is preferred, CT w/o contrast of the head is a reasonable first choice when MRI is not readily available.
Symptoms :
often resolve before the patient presents to a clinician. Historical info from witness dependent such as,
changes in behavior, speech,
memory and movement.
Sudden weakness
, numbness or paralysis in face, arm, or leg, typically on one side of body
Slurred or garbled speech
-Sudden blindness in one or both eyes
loss of balance or coordination
Atherosclerosis of extra cranial carotid and vertebral arteries.
Embolic sources and arterial dissection
Sympathomimetic drugs
Mass Lesions (tumors)
TIAs are characterized by a temporary reduction or cessation of cerebral blood flow in a specific neurovascular distribution as a result of partial or total occlusion. This happens usually from an acute thromboembolic event or stenosis of a small penetrating vessel. Clinical manifestations will vary, depending on the vessel involved and the cerebral territory it supplies.
Transient Ischemic attack (TIA)
1. ABC’S!! 2, Osmotic agent/ loop diuretic to decrease ICP
3, Caused by aneurysm: Surgical Clipping or Endovascular coiling
Diagnostic tests:
- Serum Chemistry/ABG/CBC/PT
CT without contrast***- Most Sensitive
- Lumbar Puncture- color/turbidity
- Cerebral angiogram- Criterion test for aneurysm
Headache (48%)- worst headache of my life
Dizziness (10%)
Orbital pain (7%)
Diplopia (4%)
Visual loss (4%)
Signs present before SAH include the following:
Sensory or motor disturbance (6%)
Seizures (4%)
Ptosis (3%)
Bruits (3%)
Dysphasia (2%)
Sentinel Leaks- “Warning sign” before rupture of aneurysm
-N/V, photophobia,
neck pain.
Etiology :
- Aneurysm Rupture - Most common: “Berry Aneurysm”:appears as a sac forming at the circle of willis
- Traumatic Head Injury - MVA, falls
- Rupture of arteriovenous malformations: , a tangle of blood vessels in the brain
- Infection
- Neoplasm
Subarachnoid hemorrhage (SAH) refers to a life-threatening condition in which there is extravasation of blood into the subarachnoid space between the pia and arachnoid membranes.
Subarachnoid Hemorrhage
A 58 year old man presents to the ED with a mild to moderate dull headache. The headache has steadily progressed over the past month. The patient states that the headache is worse in the morning and with coughing and sneezing. The patient also notes the recent onset of nausea and vomiting. Which of the following is the most likely diagnosis?
(A) Common Migraine Headache
(B) Cluster Headache
(C) Classic Migraine Headache
(D) Tension Headache
A 24 year old woman presents to her primary care doctor complaining of a dull, throbbing right-sided headache. The headache is associated with nausea, vomiting, sensitivity to light and sound. The headache lasts for hours and is relieved by sleep. The patient states that these types of headaches occur at least once a month and she can tell she is going to get a headache because there are holes in her vision and she sees zig-zag lines each time. What is the most likely diagnosis?
(A) Tension Headache
(B) Cluster Headache
(C) Hypotensive Headache
(D) Hypertensive Headache
A 42 year old man presents to his primary care doctor with intermittent episodes of severe headaches around his left eye and temple. The patient states that for several days in a row he gets less sleep because he is woken up nightly. However, his sleep pattern will then return to normal and he will be headache free for a couple of months but then the headaches and sleeplessness begin again. What is the most likely diagnosis?
(A) Triptans
(B) Ergot Medications
A 42 year old female presents to the ED complaining of “the worst headache of her life.” The headache was of sudden onset and associated neck stiffness and vomiting. Upon physical examination there was nuchal rigidity, however, no focal motor or sensory deficits. What is the most likely diagnosis?
(B) Biopsy
(C) Lumbar Puncture with CSF analysis
(D) CT Scan
A 62 year old female with a past medical history of polymyalgia rheumatica presents to the ED with severe scalp and temporal and jaw pain. Upon physical examination the temporal artery is palpable and tender. What is the diagnostic test of choice?
(A) MRI without Contrast
(B) MRI with Contrast
(C) MRI with & without contrast
(D) CT Scan
A 24 year old woman with poorly controlled hypertension, presents to her primary care doctor complaining of a dull, throbbing right-sided headache. The headache is associated with nausea, vomiting, sensitivity to light and sound. The headache lasts for hours and is relieved by sleep. The patient states that these types of headaches occur at least once a month and she can tell she is going to get a headache because there are holes in her vision and she sees zig-zag lines each time. Which of the following is the appropriate first line drug?
A 62 year old man with a history of diabetes and chronic atrial fibrillation presents to the ED with an acute onset of left hemiparesis involving the upper arm. Upon physical examination there is facial nerve palsy involving the lower face. Which of the following is the most likely diagnosis?
A 65 year old man with a past medical history of depression and hypertension presents to his primary care doctor for evaluation of progressive short-term memory problems, headache, and difficulty thinking of words. The patient states these symptoms have been occurring for a few months. Upon physical examination the patient is unable to recall three objects after five minutes and exhibits a right pronator drift. Which of the following would be the next most appropriate step to take in caring for this patient?
A patient presents with an acute onset of quadriplegia. His only way to communicate with the PA is by blinking or moving his eyes up and down. What is the most likely diagnosis?
(A) Trigeminal Neuralgia
(B) Spontaneous Internal Carotid Artery Dissection
(C) Locked-in Syndrome
(D) Hypoxia- Induced Headache
A 45 year old male is brought to his primary care doctor by his daughter. The daughter states that her father has been forgetting things more often such as taking his medications and has been having trouble saying words and forming coherent sentences. Upon physical examination it is noted that the patient exhibits gait disturbances. What is the most likely diagnosis?
(A) Dementia
(B) Delirium
(C) Depression
(D) Drug Overdose
(A) Acute ischemic stroke
(B) Trigeminal Neuralgia
(C) Hypoxia Induced Headache
(D) MI
(A) Intracranial Tumor
(B) Migraine Headache
(C) Classic Headache
(D) Aneurysm
(A) Suicide Headache
(B) Subarachnoid Hemorrhage
(C) Aneurysm
(D) Trigeminal Neuralgia
Body Systems

Pt. denies trauma, fainting,
, scars, or masses

Pt. denies diplopia or lid lesions, uneven eyebrow hair distribution. No blurred vision, blind spots, burning, pain, redness or pruritis. No discharge, injection, lacrimation, conjunctivitis, photophobia, or Hx or eye injury

Pt. denies frequent colds, rhinorrhea, rhinitis or decreased smell. No congestion, allergies, hx of nasal obstruction or injury, epistaxis, snoring, postnasal drip or congestion
Pt denies gingival bleeding, oral lesions, tongue discoloration, white plaques, tonsillitis, excessive salivation, voice changes, dry mouth, thrush, sore throat, or tongue. No changes in taste or abnormalities to the palate

Clinical Features
Focal symptoms are more specific and include the following:

•Aphasia- be aware of language barriers and confusion
•Visual field defects- patients are usually not aware of them until the PE or accidents, Papilledema

Seizures are common with brain tumors and provide clues to which area of the brain houses the tumor.
(e.g. otitis media)
Dental infection
Pyogenic Lung Infection
Cranial Trauma/Brain surgery
Reem Badr
Prabhdeep Gill
Antonina Michelli
Michelle Mozatto

Ribi Priyev
Reshma Sakaria
Joanna Tao
Jeanne Tsoi
Past Medical History
NKDA, NKEA, NKFA, No latex allergies
Adult Illnesses:

No known adulthood illnesses
Childhood Illnesses:
No known childhood illnesses
Psychiatric Illnesses:
Patient denies any psychiatric occurrences
Health Maintenance:
Pt. states that all immunizations are up to date
Screening Tests:
Pt screened for TB, FOB, RPR/VDRL, HIV, BSE. Pt. had a negative PAP smear and a normal mammogram.

Pt denies any past injuries or accidents
Pt denies any recent surgeries
Pt. denies transfusions
Normal Balanced Diet.
Pt. states that she exercises on a regular basis.
Sleep Patterns:
Pt. states that she
tries to get 7 hours of sleep

however is interrupted by the headaches and muscle jerking.
Safety Measures:
Pt. follows normal standard safety regulations such as fire extinguisher and carbon monoxide detector. Pt applies sunscreen and wears seat belt while driving.
Sexual History:
Patient is in a
monogamous relationship with her husband and has not been sexually active for the past few months/not involved in promiscuous activity
Personal and Social History
Pt. is a 38 year old female who is a pharmaceutical executive currently on medical leave. Pt. is married, has no children, and lives in a house with her husband. Pt. states that there is no history of any domestic violence. Pt. denies any smoking, drinking, or any illicit drug abuse.
Family History
Paternal Grandfather: Unknown
Paternal Grandmother: Unknown
Maternal Grandfather: Unknown
Maternal Grandmother: Unknown
Father: 72yo Alive with a history of prostate cancer (currently in remission) and
stroke with no complications
Mother: 70yo Alive with a history of
osteoporosis and hypercholesterolemia
Physical Examination
General Survey:
The patient is
: alert, oriented to
person and place

She could not recall today’s date/month/year. She displays
slurred speech, poor eye contact and concentration

Vital Signs:
Height (without shoes) 5'6”.
(dressed) 150lb.
24.2 (in normal range)
140/90 mmHg right arm, supine.
Heart rate
(HR): 82 and regular.
Respiratory rate
(RR): 18.

Physical Examination
Hair is of good texture and distribution. Scalp without lesions,


Conjunctiva pink; sclera white.

Left pupil is dilated more than the right. Fundoscopic exam shows papilledema bilaterally.


No cerumen/erythema in ear canals; Tympanic membranes with good cone of light. Handle of malleolus seen.


Mucosa pink, septum midline. No polyps, lesions, bleeding,

inflammation seen.


Oral mucosa pink. No erythema, edema of soft and hard palate, buccal mucosa, tongue, and posterior oropharynx. No sign of postnasal drip or exudates noted.


There is no LAD throughout. The thyroid and trachea are midline with no trauma and enlargements noted.

Physical Examination

Trauma to the right wrist with no ecchymosis.

There is no deformity tenderness, crepitus or edema upon palpation and inspection. Normal active range of motion throughout shoulders, elbows, wrists, hands, hips, knees and ankles.


MMSE Score 26/30,

Patient is alert and oriented x 2. Right sided weakness, right upper extremities with strength 3+/5, hyperreflexia with positive Babinski’s response on right side. DTRs are hyperreflexive on right side 4+. Sensory loss to temperature and pain on the right side. Positive Romberg test with eyes opened and closed
Normal gait, heel to toe, heels and toes.
Pt. is a 38 year old female presenting with a headache that is provoked by movement, and is described as a pressure-like pain in her right parietal area. Pt. has malaise, vomiting, personality changes, spasticity, and weakness on her right side. On PE, pt. has slurred speech, poor eye contact and concentration, is disoriented to time, has bilateral papilledema, anisocoria, hyperreflexia, decreased strength in right upper extremity, sensory loss to temperature and pain, and a positive Romberg test.
Rule In/Rule Out
Rule In - Brain Tumor
Rule Out - Brain Abscess
Pituitary Adenoma
Huntington's Disease
Amyotrophic Lateral Sclerosis
Transient Ischemic Attack
Subarachnoid Hemmorhage
Risk Factors
Family History
Male gender
Patient Education:
Advise patient to avoid headache provoking factors such as getting up from a seated position to quickly, jerking head movements,and driving too fast (advocate use of seat belt)
Advise patients to avoid risk factors such as radiation(cell phones,microwave etc.), smoking and exposure to infections at home or at the workplace.
Inform patient of available treatment options. Explain invasiveness and effectiveness of surgical resection as compared to chemotherapy.
Explain side effects of Radiation/Chemotherapy/Steroid treatments, for instance: weakened immune system, probable weight gain, avoidance of stopping steroids without tapering.
Pt. is instructed to return for check up two weeks after surgery or chemotherapy.
Pt is instructed to return to have BP checked and begin lifestyle changes such as exercising.
Consultations: Neurologist, Psychiatrist, Endocrinologist,
Surgery - usual treatment for most brain tumors
Craniotomy - neurosurgeon will make an opening in the skull to remove entire or most of the tumor
If tumor can't be removed completely without damage to surrounding tissue, they will remove as much as possible. Then proceed with radiation, chemotherapy or symptomatic relief with Dexamethasone to relive ICP.
Viral infection causing irritation and inflammation of the brain. Usually occurs in the very young or the very old.
Signs / Symptoms:
Low grade Fever
Mild/Severe headache
Low energy and a poor appetite
Clumsiness, unsteady gait
Confusion, disorientation
Irritability and crying more often
Light sensitivity
Stiff neck and back (occasionally)

Loss of consciousness, poor responsiveness, stupor, coma
Muscle weakness
or paralysis
Sudden change in mental functions:
"Flat" mood, lack of mood, or mood that is inappropriate for the situation
Impaired judgment
Inflexibility, extreme self-centeredness, inability to make a decision, or withdrawal from social interaction
Less interest in daily activities
Memory loss (amnesia), impaired short-term or long-term memory
Brain MRI
CT scan of the head
Culture of cerebrospinal fluid (CSF), blood, or urine
Electroencephalogram (EEG)
Lumbar puncture and CSF examination
Serology test
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