Download neurologic diagnosis

ADMISSIONS CONFERENCE
GENERAL DATA
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M.R.
34 years old/Female/Single
Right handed
Place of Birth: Oriental Mindoro
Roman Catholic
Fish vendor
Quezon City
 Date of Admission: January 29, 2010
 Informant: Patient
 Reliability: Good
CHIEF COMPLAINT
 Headache
HISTORY OF PRESENT ILLNESS
Nov, 2009
 Headache located on the left
temporal area
 pressing in character
 graded as 5/10
 No associated vomiting,
diplopia, blurring of vision, or
weakness
 Patient could still perform
usual activities
 Consult was done in a private
clinic in Olongapo
 Tramadol was prescribed
 CBC and Urinalysis were
done
HISTORY OF PRESENT ILLNESS
December 2009
 Increase in severity of
headache
 same location
 graded as 8/10
 patient still does her usual
activities
 no difficulty in ambulation
 Consult done in another
hospital in Olongapo
HISTORY OF PRESENT ILLNESS
December 2009
 CT scan was requested
 Faint enhancing lesions
in the left frontal and left
thalamus with areas of
low attenuation
 Findings may relate to
infectious/inflammatory or
neoplastic process
HISTORY OF PRESENT ILLNESS
December 2009
 Prescribed medications
 Pregabalin (Lyrica)
150mg/cap, OD for 7days
 Meloxicam(Mobic)15mg,
OD
HISTORY OF PRESENT ILLNESS
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January, 2010
Increase in severity of
headache, which would
now affect her usual
activities
HISTORY OF PRESENT ILLNESS
 Headache associated with
Diplopia & vomiting
 Consult done in Zambales
and MRI was requested.
Patient went to PGH for the
procedure however, due to
conflict in schedule, opted to
transfer to UST
January 22,
2010
REVIEW OF SYSTEMS
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Notable weight loss, loss of appetite
No fever
No rash, no pruritus
No visual disturbances, no eye, nose, or ear
discharge
 No cough, no difficulty of breathing
 No chest pain, no easy fatigability, no orthopnea,
no palpitations
REVIEW OF SYSTEMS
 No urgency, no hesitancy, no frequency, no gross
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hematuria
No diarrhea, no constipation
No heat or cold intolerance, no polydipsia, no
polyuria, no polyphagia
No easy bruisability, no bleeding, no cyanosis, no
edema
No hallucinations, no personality changes
PAST MEDICAL HISTORY
 (+) Pneumonia: treated (outpatient) with
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unrecalled antibiotics
(-)Thyroid diseases
(-)DM
(-)HPN
(-)Blood dyscrasia
(-)Malignancy
(-) asthma
(-)allergy
FAMILY MEDICAL HISTORY
 (-) Cancer
 (-) Hypertension
 (-) Renal disease
 (-) Cardiovascular disease
 (-) Tuberculosis
 (-) Hematologic disease
 (-) No endocrine disease
 (-) asthma
 (-) Allergy
Gynecologic History
 G3P3(3-0-0-3)
 Last Menstrual Period: Jan 21-24, 2010
 Past Menstrual Period: Nov 21-24, 2009
 Oral Contraceptive pill user for 13 years
 First sexual contact: 17years old
 One sexual partner
MENSTRUAL PERIOD
 Menarche: 12 years old
 Interval: every 28-30 days
 Duration: 3-4 days
 Amount: 1-2 pads per day
 Symptoms: (+)Dysmenorrhea
PERSONAL AND SOCIAL HISTORY
 Mixed diet
 Non-smoker
 Non-alcoholic beverage drinker
 Denies illicit drug use
Physical Examination
 Conscious, coherent, ambulatory, not in
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cardiorespiratory distress
BP: 130/80 PR: 82 bpm, reg RR: 20 cpm, reg T: 37.6 C
Ht: 155cm wt: 60kg BMI: 25
Warm, moist skin, (+)Verruca plantaris, right foot; no
pallor, no jaundice
Pink palpebral conjunctivae, anicteric sclera, pupils 23mm equally reactive to light, midline nasal septum,
Turbinates not congested, no nasoaural discharge, , no
masses, moist buccal mucosa, nonhyperemic posterior
pharyngeal wall, tonsils not enlarged
Physical Examination
 Supple neck, thyroid not enlarged, no palpable cervical
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lymph nodes, no anterior neck mass, no carotid bruit
Breast: symmetrical, no abnormal discharge, no skin
dimpling, no palpable axillary lymph nodes
Symmetrical chest expansion, no retractions, Clear and
equal breath sounds
Adynamic precordium, AB at 5th LICS along MCL, no
murmurs
Flat abdomen, normoactive bowel sounds, soft,
nontender, no mass
Pulses full and equal, no cyanosis, no edema
NEUROLOGIC EXAMINATION
Conscious, coherent, oriented to time, to place, and to
person
MMSE: 28/30
Olfaction intact in both nostrils
Pupils 2-3mm equally reactive to light, (+)ROR,
(-)papillededma,(-)hemorrhages, (+)Direct & consensual
pupillary reflex, no visual field cuts
Extraoculomotor muscles full and equal, (+) conjugate gaze
V1V2V3 intact sensory
NEUROLOGIC EXAMINATION
can raise eyebrows, can frown, can smile, can puff cheeks,
intact gross hearing, no lateralization on Weber’s, AC> BC
Rinne’s
can shrug shoulders equally can turn head from side-to-side
Tongue midline on protrusion, uvula midline on phonation,
NEUROLOGIC EXAMINATION
Can do finger-to-nose test and alternating
pronation-supination test with ease
(-) Romberg’s sign
Able tandem walk
No muscle atrophy, no
fasciculations, no
spasticity, no rigidity
MOTOR
4/5
5/5
4/5
5/5
4/5
5/5
4/5
5/5
(+)pronator drift , right
DEEP TENDON REFLEXES
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NEUROLOGIC EXAMINATION
No Babinski, No Nuchal rigidity
No Kernig’s, no brudzinski’s
ASSESSMENT
Intracranial Mass Lesion probably
neoplastic
(1) Primary
(2) Metastatic
PLANS
Serum Sodium, Potassium, CBC, BUN, Creatinine, Chest X ray
MRI
Mammography
CT scan of whole abdomen
Ultrasound of the whole abdomen
Referral to Neurosurgery
Referral to Gynecology
Paps Smear
Transvaginal Ultrasound
NEUROLOGIC DIAGNOSIS
I. Identify presence of neurologic problem
II. Determine the location of the neurologic
problem (anatomy)
III.Identify the lesion (pathophysiology)
Lowenstein, et al. Approach to the Patient with Neurologic Disease. Harrison’s Principles of Internal Medicine, 17th edition. 2008
NEUROLOGIC DIAGNOSIS
I. Identify presence of neurologic problem
? Focal Neurologic
Deficits
? Increased Intracranial
Pressure
Headache
Diplopia
Vomiting
? Meningeal Irritation
Lowenstein, et al. Approach to the Patient with Neurologic Disease. Harrison’s Principles of Internal Medicine, 17th edition. 2008
NEUROLOGIC DIAGNOSIS
II. Determine the location of the neurologic
problem (anatomy)
Levelize
(+) Diplopia
Localize
Level of the pons
Lateralize
Adams and Victor’s : Principles of Neurology, 8th ed. 2005
NEUROLOGIC DIAGNOSIS
III. Identify the lesion (pathophysiology)
 Temporal Profile
 Other useful
information
Lowenstein, et al. Approach to the Patient with Neurologic Disease. Harrison’s Principles of Internal Medicine, 17th edition. 2008
NEUROLOGIC DIAGNOSIS
III. Identify the lesion (pathophysiology)
 Temporal Profile
 Other useful
information
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Chronic Headache
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Gradual evolution over months
(+) diplopia, (+) vomiting
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Slowly progressing without
remissions
Consider:
Mass lesions (neoplasm, abscess,
hematoma)
Lowenstein, et al. Approach to the Patient with Neurologic Disease. Harrison’s Principles of Internal Medicine, 17th edition. 2008
HISTORY OF PRESENT ILLNESS
January 22,
2010
 MRI findings
 Multiple rim enhancing
lesions in the gray matter
junction in both frontoparietal region and left
basal ganglia with varying
amounts of surrounding
vasogenic edema and
some hemorrhagic foci