Vignettes #8

1. Vignettes #8 Ronald G. Wiley, MD, PhD ronald.wiley@vanderbilt.edu Christopher Lee, MD, MS christopher.lee@vanderbilt.edu

2. HPI: 28yo RH AAF with Hx of schizophrenia on risperidone presents to the ED for altered mental status 1 day after discharge from an outside hospital where she had recent abdominal surgery and a prolonged hospital course complicated by sepsis treated with antibiotics. During that hospitalization she also had ICU delirium with agitation/psychosis - treated with large doses of haloperidol. • PMHx, Fam Hx and Soc Hx otherwise non-contributory • Vitals/general exam: 162/93, pulse 112, RR 16 temp 38.4°C. Diaphoretic and drooling. General exam otherwise unremarkable, abdominal incision appears to be healing well • Neurological Exam: MS: not oriented to time, unable to repeat digits, anxious, dysarthric Gait: unable to ambulate Coordination: All movements slowed; bilateral dysmetria on FNF. CN: intact cranial nerves II-XII Sensory: unremarkable but unreliable due to AMS Motor: diffusely increased tone - rigid in BLEs; cogwheeling present in BUEs; minimally decreased motor strength diffusely (4/5 in all extremities); fine bilateral hand tremor at rest Reflexes: symmetric in all extremities (2+), no clonus, toes downgoing

3. HPI: 52 yo F with history of HTN, presents to the ED with unsteady gait. During the past week, she has been intermittently dizzy. 2 days ago, she began having double vision on right gaze only. Yesterday, she had tingling in her right hand with some slurred speech. Today, she awoke with right-sided numbness and was very unsteady on her feet. Vitals: P 62 BP 140/78 R 16 T 36°C Gen: lethargic, mildly rigid neck, otherwise unremarkable Neurological Exam MS – lethargic, but arousable (pain, loud name calling), complains of mild HA, mild dysarthria Gait – unable to walk Coord – moderate dysmetria on FNF and HKS with L > R CN – mild L ptosis, conjugate L gaze palsy, nystagmus on R and L gaze, diminished R corneal response, decrease pain and light touch on R face, jaw deviates L, L peripheral facial paresis Sensory – decreased pain and temp on R Motor – diffusely weak with decreased tone Reflexes – diffusely hyper-reflexic, bilateral extensor plantar responses

4. HPI: 76 yo RH WM, previously healthy, c/o acute onset of hoarseness, dysphagia, severe vertigo to where he could not stand or walk 7d ago. Sx unchanged since that time. Several days prior to the event, he suffered from intractable hiccoughs. FHx, SHx: noncontributory. No medical problems that he knows of prior to this but does admit that he did not visit the doctor much for 30yrs. No meds. Vitals: P 120 BP 100/60 R 20 w/ hiccoughs T 37°C Gen: HEENT - anhydrosis on L side, c/o dry eye (OS); o/w gen exam is wnl Neurological exam MS – lethargic, dysarthric Gait: could not walk due to balance/coordination Coord – slightly dysmetric FNF and HKS, clumsy RAM on L CN – lid ptosis on L, decreased pain and temp on L, decreased corneal reflex on L, decreased taste on L, decreased hearing on L, uvula deviates R, diminished gag on Left Sensory – decreased pain and temp on entire R half of body Motor: strength intact, but somewhat difficult to test Reflexes: 1+ throughout, downgoing toes

5. HPI: 40 yo RH WM, with no PMHx, complains of progressive Left-sided numbness, leg weakness and difficulty urinating. One year ago, he developed numbness + weakness in his Right hand, associated with tightness in the back of his neck. EMG at that time was unremarkable. 2 weeks ago, he underwent neck manipulation by a chiropractor -> his gait became rapidly more unsteady. He lost his ability to button clothes and developed numbness over the Left side of his body. FHx and SHx: are noncontributory, and he’s not on any meds. Vitals: P 94 BP 120/84 R 18 T 37°C Gen: mild limitation in flexion and rotation of neck Neurological Exam MS – intact in detail Gait – circumducts L foot Coord – mild tremor and slight dysmetria on FNF, HKS, RAM CN – moderate wasting of L sternocleidomastoid and upper trapezius, L tongue moderately atrophic Sensory – decreased pain and temp from C2 down on R and from C5 down on left, position and vibration intact Motor – hypertonic L > R, 4/5 quadriparesis L > R Reflexes – diffusely hyper-reflexic with clonus on L, bilateral extensor plantar, abdominal reflex absent, anal wink present

6. 56 yo LH AAM w/ admitted earlier today with left calf swelling, pleuritic chest pain and dyspnea now with altered mental status. Lung scan showed moderate probability pulmonary embolus. After the scan, he was noted to be confused with a temp of 38. Patient reports losing the ability to read 2 days ago. He complains of numbness of fingers on the right, but pointed to his toes when asked to outline the region of numbness. Vitals: P 100 BP 150/80 R 24 T 38.3 Gen: obese, Cushingoid, multiple spider angiomata, chest splinting on left w/ decreased breath sounds, LLE swollen and erythematous Neuro MS – oriented to place and month, recalled year w/ difficulty; speech circumlocutory w/ word-finding errors and substitutions; mild dysnomia; 1/3 recall at 5 min; poor attention; unable to calculate or read; could draw clock and write name; unable to ID fingers or body parts, R/L confusion CN – R homonymous hemianopsia Sensory – decreased stereognosis and graphesthesia in R hand; decreased vibration and proprioception in feet Coord – slightly slowed RAM on R

7. The End Congratulations and Good Luck – Keep Learning