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    Cagayan State University - College of Medicine and Surgery Clinical Neurology Oral Revalida, May 4, 2016

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    Michelle Vera Gabun
    The patient is a 29-year-old female who presented with a 2-week history of worsening headache, vomiting, and nuchal rigidity. On examination, she was drowsy and disoriented with hyperreflexia on the right side. Cranial CT scan showed a contrast-enhancing mass in the left frontal cortex. Differential diagnoses included infections and tumors. Initial workup revealed mild leukocytosis. Further diagnostic tests and management are discussed to determine the etiology and develop an appropriate treatment plan.

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    Cagayan State University - College of Medicine and Surgery Clinical Neurology Oral Revalida, May 4, 2016

    Uploaded by

    Michelle Vera Gabun
    327 views4 pages
    The patient is a 29-year-old female who presented with a 2-week history of worsening headache, vomiting, and nuchal rigidity. On examination, she was drowsy and disoriented with hyperreflexia on the right side. Cranial CT scan showed a contrast-enhancing mass in the left frontal cortex. Differential diagnoses included infections and tumors. Initial workup revealed mild leukocytosis. Further diagnostic tests and management are discussed to determine the etiology and develop an appropriate treatment plan.

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    ORAL-REVALIDA-1

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    The patient is a 29-year-old female who presented with a 2-week history of worsening headache, vomiting, and nuchal rigidity. On examination, she was drowsy and disoriented with hyperreflexia on the right side. Cranial CT scan showed a contrast-enhancing mass in the left frontal cortex. Differential diagnoses included infections and tumors. Initial workup revealed mild leukocytosis. Further diagnostic tests and management are discussed to determine the etiology and develop an appropriate treatment plan.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    327 views4 pages

    Cagayan State University - College of Medicine and Surgery Clinical Neurology Oral Revalida, May 4, 2016

    Uploaded by

    Michelle Vera Gabun
    The patient is a 29-year-old female who presented with a 2-week history of worsening headache, vomiting, and nuchal rigidity. On examination, she was drowsy and disoriented with hyperreflexia on the right side. Cranial CT scan showed a contrast-enhancing mass in the left frontal cortex. Differential diagnoses included infections and tumors. Initial workup revealed mild leukocytosis. Further diagnostic tests and management are discussed to determine the etiology and develop an appropriate treatment plan.

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    © All Rights Reserved
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    of 4

    CAGAYAN STATE UNIVERSITY – COLLEGE OF MEDICINE AND SURGERY

    CLINICAL NEUROLOGY ORAL REVALIDA, MAY 4, 2016

    CASE 1: ALTERED SENSORIUM

    The patient is BL, 29/F, admitted November 5, 2012 for the chief complaint of increase
    in sleeping time.

    HPI:
    2 wks PTA, Pt complained of generalized holocranial throbbing headache VAS
    10/10 with projectile vomiting, low grade fever, and nape pain. There was no report of
    nausea, dizziness, sinus tenderness, blurring of vision, nor loss of consciousness. She
    sought consult at a local hospital and given pain reliever which offered temporary relief.

    5 days PTA, still with generalized headache VAS 10/10 and nape pain, several
    bouts of vomiting, now associated with sudden onset right sided weakness. She was also
    noted to be irritable and disoriented. However, there was no consult done during this
    time. She self medicated with Paracetamol which offered temporary relief. No associated
    seizures, decrease in sensorium and blurring of vision.

    1 day PTA, still with above complaints, now associated with increase sleeping
    time and decreased verbal output.

    Review of Systems
    (-) anorexia, (-) significant weight loss
    (-) cough, (-) colds, (-)nasal/aural discharge, (-) sore throat
    (-) chest pain, (-) palpitations, (-) dyspnea
    (-) abdominal pain, (-) recent bowel movement changes
    (-) dysuria, (-) oliguria
    (-) hematuria, (-) hematochezia, (-) hematemesis, (-) melena
    (-) cyanosis, (-) bipedal edema
    (-) muscle and joint pains
    (-) jaundice
    (-) easy bruisability

    Past Medical History


    (-) BA, HPN, DM, CA, TB, Goiter, allergies

    Family Medical History


    (-) Similar illness/complaints in the family
    (-) Hypertension, DM, CVD, pulmonary tuberculosis, Seizures

    Personal and Social History


    She is the 2nd among 7 children. She lives with her family and works as a seamstress at a
    small garment shop. She is single, catholic, Right-handed, non-smoker, non-alcoholic,
    and non-illicit drug user.

    Physical Examination Findings

    On admission, the patient was drowsy, disoriented to time, place and person, able
    to follow one-step commands with prodding, and had delayed and inappropriate
    responses to question. The following were noted on examination:

    BP: 110/80, HR: 80s, RR: 18, Temp: 37.1C


    Pink conjunctivae, anicteric sclera, (-) sinus tenderness, (-) nasal discharge (-) cervical
    lymphadenopathy, (-)Neck vein engorgement, (-) anterior neck masses, (-) mastoid
    tenderness, (-) tonsillopharyngeal congestion, (+) dental caries
    Equal chest expansion, clear breath sounds, (-) rales, (-) rhonchi, (-) wheezes
    (-) Heaves/thrills, apex beat at the 5th intercostal space and 2 cm medial to the left
    midclavicular line, normal heart rate and regular rhythm, (-) murmurs
    Flat abdomen, normoactive bowel sounds, soft, liver edge is non-palpable, (-) spider
    angioma, umbilicus non-protruding, spleen non-palpable
    Full and equal pulses, pink nailbeds, (-) pallor, (-) edema, (-) cyanosis, (-) jaundice

    Neurologic Examination
    Drowsy, disoriented to time, place and person, able to follow one step commands with
    prodding, and had delayed and inappropriate responses to question.
    Pupils 4mm equal, briskly reactive; (-) visual field cut
    Funduscopy, OU: (+) ROR, clear media, distinct disc borders, Cup-disk ratio 0.3; AV
    ratio 2:3; (-) hemorrhages/exudates, (+) papilledema, grade 1 right OU
    Primary gaze midline, full horizontal and vertical Doll’s
    Brisk corneals, OU
    (-) Facial asymmetry
    (+) good gag reflex
    Unable to protrude tongue on command
    On motor examination, normotonic extremities with purposeful non-preferential
    movement on all extremities left more than the right
    hyperreflexic on the right, normoreflexic on the left
    (-) extensor toe signs, bilateral; (-) clonus
    (-) nystagmus
    (+) nuchal rigidity, (-) Brudzinski sign, (-) Kernig sign
    (-) abnormal sweat patterns
    GUIDE QUESTIONS:

    1. Give a 3-sentence summary of the pertinent features of the case.


    2. What neural structures are involved? What is your localization?
    3. What is the etiology of the illness? What are the differential diagnoses?
    4. Based on your main working diagnosis, what is the pathophysiology of the signs
    and symptoms seen in this patient?
    5. What is the value of each of the diagnostic tests done on this patient?
    6. What are the initial approaches to therapy?
    7. What is the prognosis for this patient

    Pertinent laboratory workups included


    Blood Type: A positive
    PT/PTT:
    PT 11.8/10.9/>1.0/1.0 PTT 35.2/34.4
    Clinical Chemistry:
    BUN 1.74 Crea 53 AST 36 ALT 42 Na 147 K 3.2 Cl 110

    CBC:
    WBC 13.67 RBC 3.66 HGB 108 HCT .330 MCV 89.1 MCH 29.5 MCHC 331
    RDW 13.3 Plt 383 Neut .720 Lymph .18 Mono .090 Eos .010

    Urinalysis:
    U/A light yellow, clear, sg: 1.005 pH 6.0 (-) sugar, protein; RBC 0-1, WBC 0-1, (-) cast,
    epith: few, Bacteria: occasional, (-) mucus, crystals

    2-D Echo:
    Normal sized L ventricle with good wall motion and contractility; preserved overall
    systolic function.

    Cranial CT scan

    Cranial imaging was done which showed contrast-enhancing 3x4 mm mass with
    prominent perilesional edema on the L mesial frontal cortex. There was no hydrocephalus
    or midline shift.

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