Acute Neurology

1. Acute Neurology Clinical Vignettes Session 6

2. You are called to the E.R. to evaluate a 23 y/o Chinese male for left ophthalmoplegia. He is a juvenile onset poorly controlled diabetic on 40 units NPH insulin per day. He only speaks Chinese and a history is otherwise unobtainable. • V/S: BP 120/70, P 72, reg., RR 16, unlabored, T 38.5o C • General examination: Remarkable for a sweet smelling breath, tenderness over the left orbit and a mild left proptosis. Left internal nares ulcer. • Neuro: • HIF: Difficult to assess because of language, he is lethargic but can follow demonstrated directions • Gait: Right external rotation of the foot with some difficulty on turning • Coordination: Could not follow directions • Cranial Nerves: • II: left fundus has no venous pulsations; venous pulsations are seen in the right fundus; right pupil 4mm and reactive; left pupil 6mm and unreactive; • III, IV, VI: Left ptosis, total external ophthalmoplegia of the left eye; right eye has full EOMs • V: Absent left corneal, seemed to not appreciate pin over left frontal-orbital area • VII-XII: Intact • Sensory: Withdrew all extremities equally from pin • Motor: Right pronator drift; • Reflexes: 3+ but slightly brisker on the right; equivocal right Babinski reflex

3. You are called to evaluate a 43 y/o female for a right ptosis. She awoke this morning with pain behind her right eye and inability to open her eye. Past history is unremarkable. • V/S: normotensive, afebrile • General examination: unremarkable • Neuro: • HIF: Intact in all spheres • Coordination and Gait: normal • Cranial Nerves: • II: Pupils 3mm equally reactive to light; right ptosis; fundi are within normal limits • III, IV, VI: Right eye rests down and out, when attempting to look down the eye intorts, there is palsy of vertical gaze and adduction. The left eye has full range of motion. • V-XII: Intact • Motor, Sensory: normal • Reflexes: 2+ equal and symmetric

4. A 56 y/o woman with breast adenocarcinoma metastatic to bone is found unresponsive in her hospital bed. She had been noted to be normal by the nursing staff 30 minutes previously. • V/S: BP 130/80 P 132 R 20-deep and reg. T 37.7o C • General examination: unremarkable • Neuro: • HIF: Comatose. No response to deep pain. • CN: II - Fundi benign • III, IV, VI - Eyes deviated to R, occasionally drifting to midline but returning to R; Oculocephalics - no doll's eyes; Pupils 5mm, equally reactive to light • V- R facial weakness • IX, X - Normal • XII - Midline • Sensory: No response • Motor: Flaccid R hemiparesis • Reflexes: 2+ L side. 1+ R side; toes - extensor bilaterally

5. The medical resident asks you to see a patient with hypertensive encephalopathy. The patient's wife states that while walking 2 hours previously, he developed sudden onset of severe vertigo and subsequent vomiting. He was able to walk to the subway station but lost consciousness on the train. • V/S: P 100, BP 250/120, R 36 periodic, T 38o C • Neuro: • HIF: Comatose, no response to deep pain • CN: Fundi show grade 2/4 hypertensive changes, no papilledema Pupils: 2mm equal, sluggish reaction to light • EOMs: resting skew deviation, right above left; Oculocephalics - absent; Oculovestibular - limited to minimal tonic deviation of both eyes to right • Corneal reflexes: intact • Spontaneous vomiting with intact cough • Motor: Bilateral spontaneous extensor posturing • Reflexes: Clonic symmetrical DTR's. Toes upgoing bilaterally • Mechanical: Neck-supple except during episodes of posturing • Lab: EKG-Showed ST depression in all left-sided leads