SNS Intern Course Case Scenarios
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Transcript of SNS Intern Course Case Scenarios
SNS Intern Course Case Scenarios
2014
Case # 7• 63 yr old left handed female presents with progressive
headache, left homonymous hemianopia and left hemiparesis.
• PMH: HTN, DM, breast cancer 12 years earlier with negative follow up
• ROS: no systemic complaints• Meds: Prozac, ASA, glucotrol, lasix
Physical Exam
Constitutional: Normal appearing, no evidence of systemic illnessNeurological: A&O x3, speech normal, memory decreasedCranial nerves: decrease vision left visual fieldMotor 4/5 leftSensory decreased leftDTRs increased on leftCerebellar normalGait normal, tandem off
Course• POD #1: Mild confusion, neurologically intact with
improved motor strength to 4+/5, some visual field deficit to the left.
• POD #5: Worsened confusion, with motor strength of 3/5 on the left
Case #8• 58 yr old female presents to your ED with sudden
headache followed by acute visual loss OU. • PMH is significant only for HTN, DM• On exam, the ED physician reports a patient in distress
with severe headache, mild meningismus, a non reactive right pupil with NLP, and left eye with light perception, finger counting.
Tests• Normal labs, except a prolactin level of 430, and low
cortisol• MRI in the Emergency Department shows an
abnormality
Course• Intraoperative findings: blood clot and likely adenoma.
Gross total resection. CSF leak intraop.
Course• POD #1: improved vision and headache, overnight urine
output increases to 400cc/hr• POD #2: Pt coughing excessively and intermittently
choking on fluid in nasopharynx
Case #9• 42 yr old right handed male presents to your hospital
with headaches, dysphasia and progressive right hemiparesis.
• PMH is significant for hypercholesterolemia• ROS: is negative for systemic complaints except chronic
cough.
Physical Examination• A&Ox3, speech hesitancy, memory intact• No meningismus• CN: intact• Motor 3/5 on the right, arm weaker than leg• Sensory, decreased on the right• DTR: increased on the right with + Babinski
Course• Day #1: Initial improvement in clinical condition• Day #3: Deterioration, with obtundation, rising fevers,
meningismus and WBC 22,000
Case #10
• 71 yr old female with a significant past medical history of HTN, DM, CRF
• The pt presents with acute right side weakness involving UE/LE
• ROS: several days of vomiting and diarrhea. No oral intake for several days.
Meds: ASA, Atrovent, Insulin, Cardizem
Physical Exam• AO x person, hospital, Mild aphasia • BP 94/50, Pulse 130• PERRL, EOMI • Face symmetric, tongue midline • LUE/LLE 4/5 • RUE/RLE 3/5
CT on Admission
MRI
CT Venogram
Repeat CT after 1 day
Course
• Negative hypercoagulable panel • CT chest/abd/pelvis – WNL
• Natural History
MRI x 6 months
Case #11• 71 y/o right handed man presents with sudden weakness
of left upper extremity, no headache, no speech loss, no pain.
• PMH: HTN and hypercholesterolemia• ROS: negative except for above• Meds: ASA, Lipitor
Physical Exam
Afebrile, BP 180/110, Pulse 70, RR 20Mental status and speech normalCranial nerves normalMotor: Left upper ext 3/5 in all muscle groupsSensory: mild left upper ext numbnessDTR and cerebellar: normal
MRI perfusion of brain
• Due to creatinine, the patient could not get a CTA or angiogram
• MRA shows a left carotid ICA stenosis of 90% with some ulcerated plaque.
• There is no tandem stenosis• No prior radiation to neck, no prior surgeries of the neck,
the bifurcation is C4-5
Course• Intraoperative monitoring shows ipsilateral hemispheric
decrease during the procedure
Case #12• 42-year-old male with 2-month with left shoulder and arm
pain
• Radiation of pain through his radial forearm to thumb and first finger
• Non-focal neurological exam with exception:– decreased (2/5) strength and reflex in the left bicep– decreased pinprick in the thumb and first finger
Course• POD #1: Arm pain is much better, mod swallowing
problems• POD#12: Arm pain returns, swallowing much worse.
Case #13• 18-year-old male s/p fall from a window, landing on his
head. At the scene, the patient is unable to move or feel his hands or legs and has severe neck pain. He can flex and extend his wrists, elbows and shoulders. He arrives on a backboard to your ED.
PMH/SH: noneROS: intoxicatedMeds: none
Physical Exam• Afebrile, BP 90/50, Pulse 45, RR 25• Laceration on occiput, neck immobilized but tender
posteriorly• Mental status is clear, but pt is intoxicated• Wrist flexion and extension 3/5, triceps, deltoids and
deltoids 5/5• Sensory C7 intact• DTRs areflexic• No rectal tone, no bulbocavernosus or abdominal
reflexes
Course• Pt does well with stabilization, pain is better. Pt transfers
to rehab.• At 3 month return visit, the patient has significant
extremity rigidity and pain, medically uncontrolled.
Case #14 • 34 yr old male with a 2 days history of progressive neck
pain, lower extremity numbness and worsening quadraparesis.
• No history of trauma, no headache• PMH: none• ROS: Recovered from recent viral illness, otherwise no
other complaints• Meds: Ibuprophen
Physical Exam• Obvious discomfort, pain with cervical ROM.• AVSS• Mental status and speech are normal• CN: Normal• Motor: deltoid 5/5. biceps, triceps, grasp and lower ext
are 3/5• Sensory: decreased in position sense and sharp pain• DTRs symmetric, rectal tone normal.
LABS• WBC: 12,000, elevated lymphocytes
Course• What is the treatment and natural history of this
disorder?