Aim Andhra Pradesh PG
Some Interesting Clinical Cases!!!!
A 44-year-old woman was brought to a clinic by her husband, who gave a history of disorientation, confusion, and of distractibility and forgetfulness. These symptoms had become more severe in the last several months. The patient had recently begun to complain of headaches and after she had what she described as "a fit", her husband insisted she see a doctor.
Neurologic examination showed apathy and difficulty focusing attention, impairment of memory, left papilledema, facial asymmetry, lack of movement on the right side of the face, and general weakness but symmetric reflexes in the remainder of the body. An electroencephalogram showed an abnormal slowwave focus in the left hemisphere. Imaging studies showed a calcified multifocal mass in the left frontoparietal region.
A brain biopsy was performed and a diagnosis made. By the next day, the patient had become comatose with dilated fixed pupils and she died soon afterward. At autopsy, findings included small hemorrhages in the brain stem and extensive pathologic changes in the forebrain.
Q:)What is a "fit"?
Q:)Is the problem with blood supply to the brain or other cause?
A:)Most likely a tumor since the problems developed over time. Problem with blood supply would have a rapid onset. It was a malignant glioma.
The mental impairment suggests a lesion in one or both frontal lobes. The right facial signs made a left-sided lesion probable, and this was confirmed by the EEG and imaging studies. The seizure also sugested an irritative lesion in or near the motor cortex.
A 45-year-old man was recovering from a mild upper respiratory tract infection when he suddenly noticed weakness in both legs while walking up the stairs. He also developed a numb sensation over the lower part of both legs and the feet. Two days later, while shaving, he noticed a weakness of the muscles on the right side of his face.
On physical examination the patient did not appear to be ill. He had no pyrexia. Examination of his leg muscles showed obvious signs of muscle weakness involving both legs, especially below the knees. Both ankle reflexes were absent and the right knee jerk was diminished. He had sensory deficits for touch and pain sensations in the distribution of the stocking area of both feet and lower legs, and a mild form of facial nerve palsy involving the right side of the face.
Q:)Would you expect damage to be central (spinal cord, brain) or peripheral? Why?
A:)The damage would involve the peripheral nervous system. The reflexes were either diminished or absent-central problems would cause hyperreflexia; sensory and motor systems were equally affected on both legs-indicating most likely peripheral involvement and no central involvement.
Q:)Would you hospitalize the patient?
A:)Yes. The peripheral nerves dealing with breathing and/or swallowing could become involved. Patient has polyneuropathy, probably Gullain-Barré syndrome.
A 63-year-old unemployed man was brought to the hospital because he had a fever and had a depressed level of consciousness. His landlady stated that he had lost weight for several months and had lately complained of fever, poor appetite, and cough. On the day of admission, he had been found in a stuporous state and had felt hot to the touch.
During the general physical examination, the patient was uncooperative and thrashed about in bed. Findings included a rigid neck, a harsh systolic murmur heard along the left sternal margin, a body temperature of 40 degrees C, and a pulse rate of 140.
The red blood count showed 3.8 million/µL and the white blood count was 18,000/µL with 80% polymorpho-nuclear leukocytes. The blood glucose level was 120 mg/dL. Lumbar puncture results showed pressure, 300 mm of water; white blood count, 20,000/µL (with mostly polymorphonuclear leukocytes); glucose, 18 mg/dL; and protein, unkown (test results were lost). Gram's stain of the CSF sediment revealed gram positive rod-shaped diplococci (pneumococci).
Q:)What does the temperature, cough and blood count suggest?
A:)It suggests an infection; poor appetite and cough suggests respiratory infection.
Q:)What does the stiffness of the neck suggest?
A:)This is nuchal rigidity and suggests meningitis. Features in common with all types of meningites are headache, fever and stiff neck.
Q:)What do the results of the lumbar puncture indicate?
A:)Confirms an infection. Decreased glucose = characteristic of infection. In purulent meningites, results would be increased pressure, cloudiness, polymorphonuclear leukocytes and protein; decreased glucose.
Q:)What is the diagnosis?
A:)Pneumococcal meningitis. Meningitis = infection of pia and arachnoid; high mortality.
Some more cases will be soon coming your way people...Peace out till then