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4/6/2017

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Case Study QT

CC: LEFT arm numbnessHPIQT 59 yo RH maleJuly 2014;20 minute episode of

Left arm dangling and “unable to wink” left eye; symptoms resolved after 20 minutes

Case Study QT

CT showed cerebral lesions concerning for metastatic disease; unable to fit in MRI scanner at hospital. Open Scanner showed 3 cm wedge shaped transcortical T2/FLAIR hyperintensity in the posterior RIGHT occipital region with diffusion restriction; plus a minimum of 5 more, smaller areas in the RIGHT frontal and parietal lobes

Nonadherent with warfarin, started on Xarelto

Case Study QT

2nd admission 9/18 after awakening with left arm numbness

3rd admission 1/19; left arm numbness while lying in bed watching TV; no other associated symptoms; resolved after 2 minutes

Recurrent symptoms during the hospital admission while sitting in a chair

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Case Study QT

Carotid Ultrasound 1/20 revealed elevated velocities in the Left ICA; estimated 50-70% narrowing and no apparent flow in the RIGHT ICA seen on CTA in September. REPEAT CTA on 1/21 occluded RICA and 50-60% LICA stenosis

Case Study QT

Past Medical History:HTN, Hyperlipidemia,

Pneumonia, Afib, Tobacco addiction, Morbid obesity

Past Surgical History:LEFT carotid endarterectomy

Sept 2014

Case Study QT

Social History:Truck DriverMarried2-4 alcoholic Beverages daily½ pack of cigarettes daily

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Case Study QT

MedicationsAtorvastatin 20mg dailyMetoprolol 50mg twice dailyXarelto 20mg dailyAspirin 325mg dailyTribenzor 20-5-12.5mg daily

Case Study QT

Review of Systems:Negative

Case Study QT

Physical Exam BP 110/70, Pulse 74 Height 5’7”

Weight 291 Pounds BMI: 45.58General Appearance Alert, well, no distress, morbidly obese No carotid bruits bilaterally Oropharynx; Mallampati class 4 Airway Apical regular without R/M/G Peripheral Circulation: Normal by

inspection

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QT Case Study

Neurologic Exam Mental Status:Alertness and orientation to time,

place and self: Normal. Recent and remote Memory: Normal. Attention & Concentration: Normal. Language: Normal. Fund of knowledge: Normal.

QT Case Study

CN II: Left lower quadrantopsia, extinguished LEFT VF to DSS

III, IV & VI: Extraocular movements Normal

V: Facial Sensation NormalVII: Facial strength NormalVIII: Hearing intact to finger rub

bilaterally, no nystagmus

QT Case Study

IX, X: Palate midlineXI: Trapezius and

Sternocleidomastoid Muscles 5/5XII: Tongue midline

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QT Case Study

Motor ExamStrength of the upper and lower

extremities were 5/5 all groups. Normal Bulk and Tone. No pronator drift. No abnormal movements were seen.

Reflexes: Deep tendon reflexes were symmetrical and normal. Plantars were flexor bilaterally

QT Case Study

Sensory: Intact to light touch temperature and vibration. Pinprick was decreased in digits 1-3 bilaterally.

Cerebellum: No impairment of finger to nose or heel to knee to shin bilaterally.

Balance: Normal

QT Case Study

Gait & Station: Base; Narrow. Able to heel, toe and tandem without difficulty. Arm swing was decreased on the LEFT.

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QT Case Study

What other physical exam testing should be

done?

Tinel’s Testing and/or Phalen’s sign

QT Case Study

Impression:RIGHT Posterior Temporal infarction

with at least 5 Right sided additional embolic small areas of infarct in the setting of Afib in July 2014

Mallampati Class 4 airway, Epworth Sleepiness scale Score 16, morbid obesity, snoring, recent stroke; suspect sleep apnea

QT Case StudyImpression:4 episodes of left arm numbness

7/2014, 9/18, 1/19 and 1/22. Positive Tinel’s signs at left elbow and both wrists; suspect carpal tunnel syndrome & left cubital tunnel syndrome

Left lower quadrantopsia and extinguishment of LEFT VF with DSS

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QT Case StudyPLAN:1. Continue Xarelto

(nonadherent with Coumadin)2.Sleep eval3. Lifestyle Modification for risk

factor mitigation: Smoking cessation, weight loss, exercise

4. NCV for Carpal Tunnel/Wrist Splints

QT Case Study

Electrodiagnostic testing was abnormal.

There was evidence of moderately sever entrapment of the right and left median nerves at the wrists (bilateral carpal tunnel syndrome).

QT Case Study

At follow up, Mr. QT reported no symptoms of carpal tunnel since wearing wrist splints.

No further ER visits!

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Case Study SM

CC: Small handwriting and decreased facial expression

HPISM 70yo RH femaleShe reported small handwriting for several months and friends have commented that she seems depressed

SM Case Study

Denies drooling, choking or difficulty swallowing

Denies falls Denies hallucinationsCan turn over in bed without

difficultyNo trouble with fine motor skillsDenies any slowness with eating,

bathing or dressing

SM Case Study

PMH:HTN, Stage I Gastric Lymphoma 2 years prior (in remission); hypothyroidism, diverticulosis, subclavian DVT, RIGHT rotator cuff tear, disseminated herpes zoster, sepsis, thrombocytopenia,

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SM Case Study

PMH cont’dSubarachnoid hemorrhage,

hyponatremia, Uncontrolled atrial fibrillation,

SM Case Study

MEDICATIONSMetoclopramide (Reglan) 10MG

3 times dailyLabetalol 200mg twice dailyZofran 8mg 3x per day Coumadin 2mg daily

SM Case Study

SOCIAL HISTORYEmployed full timeNo tobacco or ethanolNever married

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SM Case Study

Review of SystemsPositive for:Projectile vomiting, diarrhea

SM Case Study

PHYSICAL EXAMBP 112/80 Apical 76

General AppearanceAlert, well, no distress, masked faciesNo carotid bruits bilaterallyApical regular without R/M/GPeripheral Circulation: Normal by inspection

SM Case Study

Neurologic Exam Mental Status:Alertness and orientation to time,

place and self: Normal. Recent and remote Memory: Normal. Attention & Concentration: Normal. Language: Normal. Fund of knowledge: Normal.

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SM Case Study

CN II: VF Full III, IV & VI: Extraocular movements

NormalV: Facial Sensation NormalVII: Facial strength NormalVIII: Hearing intact to finger rub


SM Case Study



SM Case Study

Motor ExamStrength of the upper and lower

extremities were 5/5 all groups. Normal Bulk.

Tone increased most notably in the LEFT upper extremity. Cogwheeling rigidity bilaterally at the wrists and elbows. There was also cogwheeling at the LEFT ankle.

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SM Case Study

No pronator drift. No abnormal movements were seen.

Reflexes: Deep tendon reflexes were symmetrical and normal. Plantars were flexor bilaterally

SM Case Study

Sensory: Intact to light touch, temperature, pinprick and vibration.


Balance: Normal

SM Case Study

GAIT & STATION:She was able to rise from a chair

without using her arms. Gait was slow, stride shortened. There was decreased arm swing. There was no retropulsion. She was bradykinetic

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SM Case Study

Drawing of a spiral revealed sticking.

Handwriting was micrographic.

Motor Exam -Tremor

SM Case Study

IMPRESSION:Secondary parkinsonism due to Metoclopramide (Reglan)

PLAN: Discuss tapering Metoclopramide with Gastroenterologist

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SM Case Study

Follow up 3 months later, ALL secondary parkinsonism symptoms had resolved after metoclopramide was discontinued.

M. Emory Case Study

CC: Memory loss; 2nd opinionHPI: 86 RH femaleAccompanied by her husbandStory was NOT sequential and

difficult to followME stated “I feel dizzy, like my

head and feet are not connected.”

M. Emory Case Study

Husband stated ”she says I got to tell you something…..”–Word finding difficulty –Cannot finish her thought–Trouble balancing checkbook–Repeats questions–Spends excessive amount of time talking about plans

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M. Emory Case Study

Takes longer to complete tasksPersonality change; more

argumentativeRecipes the same, “meals not as

good”Initiates bathing and clothing

change

M. Emory Case Study

Prior Evaluation/Review of DataCT head without contrast: No

acute intracranial processCBC & CMP unremarkableStarted on Aricept, developed

bradycardia and syncope, fell, was hospitalized. Aricept discontinued. Namneda started

M. Emory Case Study

Past Medical History:Hypertension, neuropathy,

osteoarthritis, hyperlipidemia, history of atrial fibrillationPast Surgical HistoryBilateral cataract surgery 7 years prior

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M. Emory Case Study

Family History:Mother deceased from stroke,

neuropathyFather deceased from stroke,

heart disease

M. Emory Case StudySocial History:

Lives with husband/Married 52 years

Retired remedial math and Grades 1-3 teacher

Etoh: 8 ounces of red wine daily

No Tobacco

M. Emory Case Study

Medications–Atenolol 25mg ½ tab twice daily

–Caltrate 600+d 1 three times daily

–Fish oil 1000mg (2) twice daily–Gabapentin 300mg (2) three times daily

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M. Emory Case Study

Medications–Kristalose 20GM as needed–Voltaren 1% Gel–Warfarin 2.5 mg tabs; dose based on INR

M. Emory Case Study

Review of SystemsPositive for:Irregular heart beat,

constipation, joint pain, loss of balance, sinus problems related to allergies

M. Emory Case Study

PHYSICAL EXAM BP 122/58 Apical 72

Ht. 5’8” Wt. 190# BMI 28.89General AppearanceAlert, well, no distress, Well groomed.No carotid bruits bilaterallyApical regular without R/M/GPeripheral Circulation: Normal by inspection

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M. Emory Case Study

Neurologic Exam Mental Status: MMSE was 29/30. One point was lost for

short term recall. She drew a clock and placed the hands so the time demonstrated 11:10 without difficulty.

She was tangential, pleasant and cooperative.

M. Emory Case Study

Funduscopic exam without evidence of hemorrhages, exudate or papilledema.CN II: VF Full III, IV & VI: Extraocular movements

NormalV: Facial Sensation NormalVII: Facial strength NormalVIII: Hearing intact to finger rub


M. Emory Case Study



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M. Emory Case Study

Motor ExamStrength of the upper extremities

was 5/5 EXCEPT decreased range of motion and strength RIGHT shoulder. All groups in the lower extremities were 5/5. Normal Bulk.

Normal bulk and Tone.

M. Emory Case Study

No pronator drift. No abnormal movements were seen.

Reflexes: Deep tendon reflexes were 1+/4 and symmetrical. Plantars were flexor bilaterally.

No forced hand grasping or palmomental sign

M. Emory Case Study

Sensory: Intact to light touch temperature and vibration.


Balance: Normal

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M. Emory Case Study

Gait & Station: Base; Narrow. Able to heel, toe and tandem without difficulty.

M. Emory Case Study

KEY Question:

When did you first notice the symptoms:

M. Emory Case Study

Answer:

“After she fell on February 5 in Florida”

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M. Emory Case Study

Impression:Sudden onset of a constellation

of symptoms which include: decreased memory, impaired concentration, word finding issues, irritability and dizziness following a fall on 2/5.

M. Emory Case Study

The sudden onset of her symptoms following a fall with a head injury leads me to the diagnosis of postconcussive syndrome. Dementia is NOT sudden onset; therefore making this diagnosis less likely.

M. Emory Case Study

PLAN:MRI of Brain with and without

contrast evaluate for structural lesion

EEGCBC, CMP, B12, Folate, Free T4,

TSH and Vitamin D

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M. Emory Case Study

Physical therapy for gait training safety and balance.

Keep previously scheduled appointment with ortho for RUE

M. Emory Case Study

Follow Up 1 month later:MRI was completed and

compared with a prior MRI from 2003.Impression read: No acute intracranial abnormality, hemorrhage or mass. Cerebral atrophy and some temporal lobe predominance and mild progression compared to August 2003.

M. Emory Case Study

EEG was normalB12 386 Folate 17.2TSH 1.13 and Vitamin D 37.5Dizziness resolved, some

lingering trouble with recall (names). No longer argumentative “no cooking boo boos”.

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M. Emory Case Study

80% of baselineNamenda tapered and stopped

Follow Up 3 months later“Either at baseline or close to it”

Hedy Ache Case Study

CC: Right sided headache for 3 months

HPI: 91 RH femaleAccompanied by her daughterVague head discomfort, does not

like the word “pain” started in December (seen 3/16)


Characterizes symptom as “vague discomfort”

Points to RIGHT parietal region to indicate that is where the pain started.

Pain radiates forward to right temporal area.

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Pain is intermittentAbsent more than present“Feels like thumb tacks are being

pushed in to my head”Duration of discomfort is a few

secondsSeveral “flashes of pain” in a row


Can be pain free for hours or days

When discomfort MOST bothersome was occurring 5-6 times per day.

Severity 0.5/0-10.


No triggering eventDenies neck painNo visual loss, but vision is

blurry, has macular degenerationDenies jaw claudication

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Reports symptoms in January to PCP

PCP refers to rheumatology for suspicion of temporal arteritis

CRP 1/25 was 2.8 (0-4.9)2/6 starts Prednisone 30mg daily


February 10, temporal artery biopsy “No arteritis identified”

Remained on Prednisone 40mg daily until 3/13 with taper started.

When I saw her she was on 30mg.


One year prior used a walker intermittently

Since starting prednisone, using walker constantly

“feels like limp noodle”Sense of generalized weakness

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Past Medical History:Atrial Fibrillation, COPD,

Alopecia,Past Surgical History:Tonsillectomy age 4,

Appendectomy age 17, hysterectomy in her 70s, bilateral cataract surgery


Family History: Non-contributorySocial History: Lives with daughterDenies tobacco, social ethanol


Medications:Zetia 10mg dailyErgocalciferol 50,000 units

weeklyPrednisone 40mg dailyIron 25mg dailyOmeprazole 40mg daily

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MedicationsMetoprolol 25mg ER (2) tabs

dailyCoumadinBiotin 5000mcg dailyAzor 5-20 1 tab dailyLevothyroxine 88mcg daily


Review of Systems:Negative!Pertinent Negatives

–Denied fever, visual changes or weight loss


Physical Exam122/60 Pulse 100 Weight 114

pounds, Height 58 inches, BMI: 23.82

General AppearanceAlert, well, no distress, Well

groomed. Appears younger than stated age. Temporal arteries nontender to palpation

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No carotid bruits bilaterallyApical irregularly irregular without

R/M/GPeripheral Circulation: Normal by

inspection


Neurologic ExamMental Status:Alertness and orientation to

time, place and self: Normal. Recent and remote Memory: Normal. Attention & Concentration: Normal. Language: Normal. Fund of knowledge: Normal


Funduscopic exam without evidence of hemorrhages, exudate or papilledema. CN II: VF Full III, IV & VI: Extraocular movements

Normal V: Facial Sensation Normal VII: Facial strength Normal VIII: Hearing intact to finger rub


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Motor ExamStrength of the upper

extremities was 5/5 proximally and distally in all groups in the upper and lower extremities were 5/5. Normal Bulk.

Normal bulk and Tone


No pronator drift. Subtle postural and kinetic

tremorReflexes: Deep tendon reflexes

were 2/4 and symmetrical. Plantars were flexor bilaterally.

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Sensory: Intact to light touch temperature and vibration..


Balance: Unsteady


Gait & Station: Unable to rise from a chair without

using her arms.Base; Narrow. Gait was assessed

without her walker. Stride was shortened. Required contact guard for heel, toe and tandem gait walking.

Romberg: Negative; sway, but no fall


Impression:Occipital Neuralgia1. MRI Brain with & without

contrast eval for structural lesion in the setting of new onset headache.2. Start gabapentin 100mg and

titrate to 100mg 3 times daily

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ImpressionCorticosteroid myopathy1. Check ESR, CRP, CPK,

Aldolase, LDH2. Taper prednisone per

rheumatology


Impression:Abnormal Gait1. Physical therapy for gait

training, safety, balance and endurance.


Temporal Arteritis Double vision or

sudden, permanent loss of vision

Throbbing headache in the temples

Fatigue, Weakness Temporal artery

tenderness Jaw Pain Fever Weight loss

Occipital Neuralgia Characterized by

piercing, throbbing or electric shock like pain in the upper neck, back of head and behind the ear.

Typically the pain is on one side of the head.

neurology np case study - c.ymcdn.comc.ymcdn.com/sites/ · gait & station: base; narrow. able...

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