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Embed code for: Case Studies for Neurological Problem Solving
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Nervous System Disorders
When answering each question: please use correct terminology (I should not see “difficulty with communication or speaking”—these would be aphasia or
dysarthria. I should not see “shaking”, I should see tremors). Please answer each with details. Spelling should be accurate.
Case Study 1
Mr. Q, age 64 years, developed a severe headache several hours ago that has not responded to acetaminophen. Now his speech is slurred, and his right arm and the right side of his face
feel numb. He is very anxious and is transported to the hospital. Mr. Q has a history asymmetry and a blood pressure of 220/110 Hg mm. He is having some difficulty following directions. An angiogram indicated narrowing of the carotid arteries.
1. Discuss the pathophysiology related to his symptoms:
a. What is the likely diagnosis?
b. Why do you believe that?
c. Discuss thrombus vs. embolus.
d. Describe the stages in the development of an atheroma.
2. Which vessel is likely involved?
3. Explain the predisposing factors in this case, and relate Mr. Q’s initial signs to the pathological changes.
4. Discuss the treatments available after first aid for this type of patient and the patient’s prognosis.
of smoking and arteriosclerosis, and there is family history of CVA and diabetes. Assessment at the hospital indicated weakness on the right side, including facial
Relate to MR. Q symptoms
a. The likely diagnosis for Mr. is a CVA of the left hemisphere of the brain.
b. I believe that Mr. Q had a CVA because he has sign and symptoms of dysarthria with R
arm and R side of his face feeling numb, he has HTN with facial asymmetry.
Thrombotic strokes are caused by a blood clot attached within a blood vessel inside of the brain.
c. Embolic strokes are caused by an atheroma that develops elsewhere in the body and travels to a blood vessel to the brain through the circulator system.
d. Stages in the development of an atheroma
Atherosclerosis as a chronic inflammatory and healing response of the arterial wall to endothelial injury
Stages of development of atheroma
1. Endothelial dysfunction or injury
2. Accumulation of lipoproteins (LDL and oxidized LDL) in vessel wall
3. Monocyte adhesion and migration into intima
Transformation into macrophages and foam cells
4. Platelet adhesion
5. Factor release by platelets, macrophages, vascular wall
Recruits smooth muscle cells from media and circulating precursors
6.Smooth muscle cell proliferation and ECM product
7. Continued lipid accumulation
The middle cerebral artery is the vessel that are likely involved.
Mr. predisposing factor include a history of smoking and arteriosclerosis with a family history of CVA’s and diabetes.
Rapid treatment with the clots busting drug (TPA) has shown to reduce the effects of a CVA in some individuals, although screening is needed to rule out a hemorrhage. Other contraindication of anticoagulant drugs is essential. Surgical intervention may be apossible to remove the obstruction from the artery. Glucocorticoids may reduce cerebral edema. The medical issues need to have a team approach for caring for MR. Q including OT, PT, SLP medication management for HTN and blood thinner to prevent any future problems or complications due to impairment that has already occurred.
Case Study 2
Ms. J, a 19-year-old college student, has been living in a dormitory on campus. She began experiencing severe headaches, neck pain, and nuchal rigidity, along with irritability and nausea. She noticed that when lying with her hips flexed, she found it very hard to stretch out her legs. Within a day her condition deteriorated, she experienced a tonic-clonic seizure, and she was quickly admitted to the hospital. Tests revealed increased intracranial pressure, fever, and leukocytosis.
Describe the pathophysiologic changes associated with the symptoms she is demonstrating.
What is the likely diagnosis?
Why do you believe that?
Focal vs Diffuse: discuss in relation to symptoms
Discuss the diagnostic tests that would likely follow admission to the hospital:
What are the likely characteristics of the CSF to be found in this case?
Which signs indicating elevated intracranial pressure are likely to be present?
What other symptoms may be present and what are they if left untreated?
Discuss the treatments available to help this patient and possible long-term complications.
Case Study 2 Related to Ms. J
Ms. J likely diagnosis is Meningitis
I believe that Meningitis, because of the sudden onset of meningitis is common and it includes sign and symptoms such as severe headache, back pain, nuchal rigidity kerng’s and Brudzinski’s sign. Chills and fever with leukocytosis also indicate infection. Ms. J has most of the signs and symptoms.
The membranes are continuous around the CNS and CSF flows in the subarachnoid space, infection spreads fast through the coverings of the brain. Focal signs are absent because there is no localized mass of infection. The meningitis diffuses all over the body and the symptoms are all over the body.
Examination of CSF, obtained by a spinal tap confirms the diagnosis.
If meningitis is present, the CSF pressure is elevated, will appear cloudy with increased number of leukocytes.
Vomiting, irritability and lethargy continuing to stupor are common early indicators of increased ICP.
Potential complications include hydrocephalus, if CFS flow is blocked by pus or adhesions and cranial nerve damage. In some case damage to the cerebral cortex may occur resulting in mental retardation seizures or motor impairment.
Aggressive antimicrobial treatment is required if is a bacterial infection. Also specific treatment for ICP and seizures along with glucocorticoids to help reduce cerebral inflammation, edema. The mortality rate in neonatal meningitis is high and there is some risk of permanent brain damage in young children. Vaccinations can prevent some types of meningococcal S. pneumonia and H. influenza meningitis when an outbreaks occur. Page 351
Case Study 3
Mr. N, age 66 years, has noticed excessive fatigue, muscle aches, and weakness in his legs for some time. His hands were shaking slightly, although his wife reported that the shaking appeared to stop when he fell asleep. Some unintentional head movements were also apparent. He remembers that his grandfather died in his mid-60s after suffering for years from a condition with similar symptoms. After several tests and the elimination of some other neuromuscular conditions, a diagnosis was made.
Discuss the pathophysiology of the symptoms he is demonstrating:
Discuss the usual progression of the likely diagnosis if it develops further.
Describe the complications that frequently develop, including the rationale for each and the early indications of each problem.
Discuss the treatments available to this patient.
Case Study 4
Mr. G, age 79 years, has always been physically active. He walks long distances on a daily basis and works out with weights. While lifting weights one day, he experienced severe lower back pain that radiated down his left leg. The leg also felt weak.
Discuss the pathophysiological changes and the probable location of the changes.
Explain why Mr. G. was told to notify the physician immediately if he was unable to urinate.
Why is it important for Mr. G. to use muscle relaxant drugs and apply heat at this stage?
Discuss possible complications and any further treatment that might be required.
Explain why this diagnosis may cause recurrent problems.
Case Study 5
Susan is 3 years old. She has a small bulge on her lower back. She is unable to walk and demonstrates paraplegia in both lower extremities.
Explain how this diagnosed.
What other symptoms may be present?
Case Study 6
Mr. M, age 24 years, developed a severe headache several hours ago that has not responded to medication and has continued to worsen. Now he is having trouble processing directions and answering questions. His right arm and leg are weak. Once at the hospital he lost consciousness.
Discuss the pathophysiology related to his symptoms:
Where is likely location of issues?
Diffuse vs local
Which vessel is likely involved?
What are treatment options for this patient?
What would a differential diagnosis for this condition be?
Case Study 7
Melanie was in a car accident. She presented to the ER with mild confusion, decreased orientation, double vision, and difficulty speaking. She has a laceration on her forehead that required 8 staples.
Discuss diffuse vs local
What other symptoms are likely to be present? Why?
What is the likely course of the hospitalization?
What are treatment options for this patient?s and cranial nerve damage. In some case damage to the cerebral cortex may occur resulting in mental retardation seizures or motor impairment.
Discuss the pathophysiological changes and the probable location