CPC#7February 28, 2006.ppt

CPC#7February 28, 2006 Victor C. Urrutia, MD Assistant Professor of Neurology Cerebrovascular Division Johns Hopkins University Case summary 59 y/o Korean woman “Chief complaint”: Change of mental status 4 week history of severe headaches and increasing “confusion” Confusion described as: Somnolence and difficulty speaking Diagnosed with proliferative and membranous glomerulonephritis a year earlier and treated with Prednisone and Mycophenolate Mofetil Case summary History of retinal vein thrombosis, hypertension, oral thrush and Lupus related serositis. Blood pressure:120/55, temperature: 37.5°C. She was lethargic, not oriented to time, had a right Hemiparesis and bilateral up going toes. A MMSE was done 18/30. No nuchal rigidity. Localization An altered mental state localizes the problem to a lesion affecting a structure of the reticular activating system or its projections to the cortex bilaterally The RAS is localized in the brainstem Reticular Activating System Four basic mechanisms Meningeal irritation Meningitis, subarachnoid hemorrhage Focal/Space occupying lesion Tumor, abscess, infarction, hematoma, hydrocephalus Metabolic/Toxic Drugs, renal, liver, fever, hypoxia, acid/base Seizures Our case Right hemiparesis No major metabolic abnormalities No nuchal rigidity No clinical history of seizures By examination her change in mental status falls into the “Focal/Space Occupying Lesion” category History of Present Illness The history of present illness should give us the “process” Her symptoms started 4 weeks ago with headache and worsening mental status with difficulty expressing herself There is a subacute history of progression and onset of symptoms Focal/Space Occupying Lesion Tumor Abscess Infarct Hemorrhage Hydrocephalus Edema CNS Involvement in Lupus Involvement of the CNS is a major source of morbidity and mortality in Lupus 70% of patients with SLE have neurological problems at some point of their course Neuropsychiatric disorders are the mos