Case Files Neurology - part 1 ppt

As new research and clinical experiencebroaden our knowledge, changes in treatment and drug therapy are required.The authors and the publisher of this work have checked with sources beli

Case Files ™

Neurology

Medicine is an ever-changing science As new research and clinical experiencebroaden our knowledge, changes in treatment and drug therapy are required.The authors and the publisher of this work have checked with sources believed

to be reliable in their efforts to provide information that is complete andgenerally in accord with the standard accepted at the time of publication.However, in view of the possibility of human error or changes in medical sci-ences, neither the editors nor the publisher nor any other party who has beeninvolved in the preparation or publication of this work warrants that the infor-mation contained herein is in every respect accurate or complete, and they dis-claim all responsibility for any errors or omissions or for the results obtainedfrom use of the information contained in this work Readers are encouraged toconfirm the information contained herein with other sources For example and

in particular, readers are advised to check the product information sheetincluded in the package of each drug they plan to administer to be certain thatthe information contained in this work is accurate and that changes have notbeen made in the recommended dose or in the contraindications for adminis-tration This recommendation is of particular importance in connection withnew or infrequently used drugs

ERICKA SIMPSON, MD

Assistant Professor, Neurology Weill-Cornell Medical College, New York Co-Director MDA Neuromuscular Clinics and Director of ALS Clinical Research Division Methodist Neurological Institute

Program Director The Methodist Hospital Neurology Residency Houston,Texas

MILVIA PLEITEZ, MD

Assistant Professor, Neurology Weill-Cornell Medical College, New York Methodist Neurological Institute Houston,Texas

DAVID ROSENFIELD, MD

Professor, Neurology Weill-Cornell Medical College, New York Director EMG and Motor Control Laboratory Methodist Neurological Institute

Houston,Texas

RON TINTNER, MD

Associate Professor, Neurology Weill-Cornell Medical College, New York Co-Director Movement Disorders and Rehabilitation Center

Methodist Neurological Institute Houston,Texas

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DOI: 10.1036/0071482873

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Professional

Want to learn more?

To Dr Alan L Kaplan, whose generosity, clinical and educational excellence, and impeccable character have set a high standard for

so many of us.

—ECT

To my eternal source of peace and strength, Jesus Christ;

to my son, Christopher, who is my daily inspiration and joy;

to my Mentor and Chair, Stanley H Appel for setting a standard of

excellence and leadership—I thank you.

—EPS

Copyright © 2008 by the McGraw-Hill Companies, Inc Click here for terms of use

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For more information about this title, click here

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James Ling, MD

Assistant Professor, Neurology

Methodist Neurological Institute

Weill-Cornell Medical College

Research Post-doctoral Fellow;

Cain Foundation Laboratories;

Assistant Professor of Child Neurology

Director, Medical Student Neurology Education

Departments of Neurology and Pediatric Neurology

Baylor College of Medicine

x i

This is the first Case Files book that has originated from The Methodist

Hospital-Houston It is dedicated to DR ALAN L KAPLAN, the excellent,

insightful, and compassionate chairman of the Department of Obstetrics andGynecology at The Methodist Hospital and professor of Obstetrics andGynecology at the Weill Medical College of Cornell University He receivedhis medical degree in 1955 from Columbia University of Physicians and Surgeons

in New York He completed his residency at Columbia Presbyterian MedicalCenter in 1959 He then served two years in the Army, following which hereturned to Columbia Presbyterian Medical Center for fellowship training,which he completed in 1963 He joined Baylor College of Medicine in 1963and was with the Department of Obstetrics and Gynecology for 42 years Heserved as Professor and Director of the Division of Gynecologic Oncology

Dr Kaplan became a certified Diplomate of the American Board of Obstetricsand Gynecology in 1966, and earned his certification in Gynecologic Oncology

in 1974 Dr Kaplan is a member of numerous professional societies, many ofwhich relate to his specialty field—female cancers He has served on variouseditorial boards and is active on committees of both the professional organi-zations and the hospitals at which he practices In his clinical practice, he caresfor women with gynecologic surgical problems and female cancers He enjoysjogging, swimming, reading, and tennis

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x v i I N T RO D U C T I O N

PART I

1 Summary—the salient aspects of the case are identified, filtering outthe extraneous information The student should formulate his or hersummary from the case before looking at the answers A comparison

to the summation in the answer will help to improve one’s ability tofocus on the important data, while appropriately discarding the irrele-vant information, a fundamental skill in clinical problem solving

2 A straightforward answer is given to each open-ended question

3 The Analysis of the Case, which is comprised of two parts:

a Objectives of the Case—a listing of the two or three main ples that are crucial for a practitioner to manage the patient Again,the student is challenged to make educated “guesses” about theobjectives of the case on initial review of the case scenario, whichhelp to sharpen his or her clinical and analytical skills

princi-b Considerations—A discussion of the relevant points and briefapproach to the specific patient

PART II

Approach to the Disease Process—This has two distinct parts:

a Definitions or neurophysiology—terminology or neuroanatomycorrelates pertinent to the disease process

b Clinical approach—a discussion of the approach to the clinicalproblem in general, including tables, figures, and algorithms

PART III

Comprehension Questions—Each case contains several multiple-choice tions that reinforce the material, or introduce new and related concepts.Questions about material not found in the text will have explanations in theanswers

ques-PART IV

Clinical Pearls—A listing of several clinically important points that are ated as a summation of the text and to allow for easy review such as before anexamination

reiter-This page intentionally left blank

4 CASE FILES: NEUROLOGY

completely new problem? The duration and character of the complaint,associated symptoms, and exacerbating/relieving factors should berecorded The chief complaint engenders a differential diagnosis, andthe possible etiologies should be explored by further inquiry

CLINICAL PEARL

❖ The first line of any presentation should include age, gender, marital

status, handedness, and chief complaint Example: A 32-year-old

married white right-handed male complains of left arm weaknessand numbness

4 Past Medical History:

a Major illnesses such as hypertension, diabetes, reactive airway ease, congestive heart failure, angina, or stroke should be detailed

dis-i Age of onset, severity, end-organ involvement

ii Medications taken for the particular illness including anyrecent changes to medications and reason for the change(s).iii Last evaluation of the condition (example: when was the laststress test or cardiac catheterization performed in the patientwith angina?)

iv Which physician or clinic is following the patient for thedisorder?

b Minor illnesses such as recent upper respiratory infections should

be noted

c Hospitalizations no matter how trivial should be queried

5 Past Surgical History: Note the date and type of procedure performed,indication, and outcome Surgeon and hospital name/location should

be listed This information should be correlated with the surgical scars

on the patient’s body Any complications should be delineated ing anesthetic complications, difficult intubations, and so forth

includ-6 Allergies: Reactions to medications should be recorded, includingseverity and temporal relationship to medication Immediate hypersen-sitivity should be distinguished from an adverse reaction

7 Medications: A list of medications, dosage, route of administration andfrequency, and duration of use should be developed Prescription, over-the-counter, and herbal remedies are all relevant If the patient is cur-rently taking antibiotics, it is important to note what type of infection

is being treated

HOW TO APPROACH CLINICAL PROBLEMS 5

8 Immunization History: Vaccination and prevention of disease is one ofthe principal goals of the family physician; however, recording theimmunizations received including dates, age, route, and adverse reac-tions if any is critical in evaluating the neurology patient as well

9 Social History: Occupation, marital status, family support, and cies toward depression or anxiety are important Use or abuse of illicitdrugs, tobacco, or alcohol should also be recorded

tenden-10 Family History: Many major medical problems are genetically mitted (e.g., hemophilia, sickle cell disease) In addition, a family his-tory of conditions such as breast cancer and ischemic heart disease can

trans-be a risk factor for the development of these diseases Social historyincluding marital stressors, sexual dysfunction, and sexual preferenceare of importance

11 Review of Systems: A systematic review should be performed butfocused on the life-threatening and the more common diseases Forexample, in a young man with a testicular mass, trauma to the area,weight loss, and infectious symptoms are important to note In an eld-erly woman with generalized weakness, symptoms suggestive of car-diac disease should be elicited, such as chest pain, shortness of breath,fatigue, or palpitations

Physical Examination

1 General appearance: Note mental status, alert versus obtunded, ious, in pain, in distress, interaction with other family members andwith examiner Note any dysmorphic features of the head and bodymay also be important for many inherited or congenital disorders

anx-2 Vital signs: Record the temperature, blood pressure, heart rate, and piratory rate An oxygen saturation is useful in patients with respiratorysymptoms Height and weight are often placed here with a body massindex (BMI) calculated (BMI = kg/m2or lb/in2)

res-3 Head and neck examination: Evidence of trauma, tumors, facial edema,goiter and thyroid nodules, and carotid bruits should be sought Inpatients with altered mental status or a head injury, pupillary size,symmetry, and reactivity are important Mucous membranes should beinspected for pallor, jaundice, and evidence of dehydration Cervicaland supraclavicular nodes should be palpated

4 Breast examination: Inspection for symmetry and skin or nipple tion as well as palpation for masses The nipple should be assessed fordischarge, and the axillary and supraclavicular regions should beexamined

retrac-5 Cardiac examination: The point of maximal intensity (PMI) should beascertained, and the heart auscultated at the apex as well as base It isimportant to note whether the auscultated rhythm is regular or irregular.Heart sounds (including S3and S4), murmurs, clicks, and rubs should becharacterized Systolic flow murmurs are fairly common as a result of theincreased cardiac output, but significant diastolic murmurs are unusual.

6 Pulmonary examination: The lung fields should be examined atically and thoroughly Stridor, wheezes, rales, and rhonchi should berecorded The clinician should also search for evidence of consolida-tion (bronchial breath sounds, egophony) and increased work ofbreathing (retractions, abdominal breathing, accessory muscle use)

system-7 Abdominal examination: The abdomen should be inspected for scars,distension, masses, and discoloration For instance, the Grey-Turner sign

of bruising at the flank areas can indicate intraabdominal or toneal hemorrhage Auscultation should identify normal versus high-pitched and hyperactive versus hypoactive bowel sounds The abdomenshould be percussed for the presence of shifting dullness (indicatingascites) Then careful palpation should begin away from the area of painand progress to include the whole abdomen to assess for tenderness,masses, organomegaly (i.e., spleen or liver), and peritoneal signs.Guarding and whether it is voluntary or involuntary should be noted

retroperi-8 Back and spine examination: The back should be assessed for try, tenderness, or masses The flank regions particularly are important

symme-to assess for pain on percussion that may indicate renal disease

9 Perform genital examination and rectal examination as needed

10 Extremities/Skin: The presence of joint effusions, tenderness, rashes,edema, and cyanosis should be recorded It is also important to notecapillary refill and peripheral pulses

11 Neurologic examination: Patients who present with neurologic plaints require a thorough assessment including mental status, cranialnerves, muscle tone, and strength, sensation, reflexes, and cerebellar

com-function, and gait to determine where the lesion or problem is located

in the nervous system Locating the lesion is the first step to

generat-ing a differential of possible diagnoses and implementgenerat-ing a plan formanagement

a Cranial nerves need to be assessed: ptosis (III), facial droop (VII),hoarse voice (X), speaking and articulation (V, VII, X, XII), eyeposition (III, IV, VI), pupils (II, III), smell (I); visual acuity andvisual fields, pupillary reflexes to light and accommodation; hearing

HOW TO APPROACH CLINICAL PROBLEMS 7

acuity and Weber and Rinne test, sensation of three branches of V

of face; shrug shoulders (XI), protrude tongue (VII)

b Motor: Observe for involuntary movements, muscle symmetry(right vs left, proximal vs distal), muscle atrophy, gait Havepatient move against resistance (isolate muscle group, compareone side vs another, and use 0–5 scale)

c Coordination and gait: Rapid alternating movements, point-to-pointmovements, Romberg test, and gait (walk, heel-to-toe in straightline, walk on toes and heels, shallow bend and get up from sitting)

d Reflexes: biceps (C5,6), triceps (C6,7), brachioradialis (C5,6),patellar (L2–4), ankle (S1–2)

e Clonus and plantar reflex

f Sensory: Patient’s eyes should be closed, compare both sides ofbody, distal versus proximal; vibratory sense (low pitched tuningfork); subjective light touch; position sense, dermatome testing,pain, temperature

g Discrimination: Graphesthesia (identify number “drawn” onhand), stereognosis (place familiar object in patient’s hand), andtwo-point discrimination

12 Mental status examination: A thorough neurologic examination requires

a mental status examination The Mini-Mental Status examination is aseries of verbal and non-verbal tasks that serves to detect impairments

in memory, concentration, language, and spatial orientation

CLINICAL PEARL

❖ A thorough understanding of functional anatomy is important to

optimally interpret the physical examination findings

13 Laboratory assessment depends on the circumstances

a Complete blood count (CBC) can assess for anemia, leukocytosis(infection), and thrombocytopenia

b Basic metabolic panel: electrolytes, glucose, blood urea nitrogen(BUN) and creatinine (renal function)

c Urinalysis and/or urine culture to assess for hematuria, pyuria, orbacteruria A pregnancy test is important in women of child-bearing age

d Aspartate aminotransferase (AST), alanine aminotransferase(ALT), bilirubin, alkaline phosphatase for liver function; amylaseand lipase to evaluate the pancreas

e Cardiac markers (creatine kinase myocardial band [CK-MB], ponin, myoglobin) if coronary artery disease or other cardiac dys-function is suspected