acute neurology – clinical vignettes.pptVIP

Acute Neurology – Clinical Vignettes Ronald G. Wiley, MD, PhD VA 873-7510 “ronald.wiley@vanderbilt.edu” General approach Question/answer #1: Is patient biologically sick? (vs behavioral issues) If so, how sick? (i.e. critically or not so serious?) Composite opinion that requires clinical judgment. Question/answer #2: What part of nervous system is malfunctioning? Functional anatomy - based primarily on neurological exam. Exam is an exercise in localization - first, pathophysiology - second. Question/answer #3: What is/are likely etiology(s)? Pathophysiology - based on all available information (history, exam findings, lab), but heavily dependent on history) Critical issues include - precise symptoms, mode and time of onset of symptoms, evolution of symptoms with time, associated symptoms/events, effects (±) of activities/therapies on symptoms, concurrent conditions, medications Reading: Posner,JB, Saper,CB, Schiff,N. and Plum,F. Diagnosis of Stupor and Coma, 2007. 1. A 26 y/o woman, previously in excellent health, complained of the worst headache in her life which developed over a 2-3 hour period. This did not prevent her from her usual duties, but 8 hours later (at 2:00 am) she awoke with a severe headache, nausea, vomiting and rapidly became unresponsive. V/S: B.P. 100/60; P 96, reg; RR 10, shallow; T 36.8o C General medical exam is unremarkable. Neuro: HIF (~mental status): unresponsive to verbal stimuli. Cranial Nerves - II. No response to threat; fundi-normal; pupils are 2mm and sluggishly reactive to light. III, IV, VI: Full EOMs to the dolls head maneuver. V. Trace corneal response bilaterally. VII. No grimacing. Motor/Sensory; increased tone bilaterally; flexor posturing in upper extremities and extensor posturing in the lower extremities to noxious stimuli bilaterally. Reflexes; 3+ bilaterally, unsustained ankle clonus; bilateral Babinski reflex