Acute NeurologyAcute Neurology

Clinical VignettesClinical Vignettes

Session 6Session 6

1. You are called to the E.R. to evaluate a 23 y/o Chinese male for left ophthalmoplegia. He is a juvenile onset poorly controlled diabetic on 40 units NPH insulin per day. He only speaks Chinese and a history is otherwise unobtainable.

V/S: BP 120/70, P 72, reg., RR 16, unlabored, T 38.5o CGeneral examination: Remarkable for a sweet smelling breath, tenderness over

the left orbit and a mild left proptosis. Left internal nares ulcer.Neuro:HIF: Difficult to assess because of language, he is lethargic but can follow

demonstrated directionsGait: Right external rotation of the foot with some difficulty on turningCoordination: Could not follow directionsCranial Nerves: II: left fundus has no venous pulsations; venous pulsations are seen in the

right fundus; right pupil 4mm and reactive; left pupil 6mm and unreactive; III, IV, VI: Left ptosis, total external ophthalmoplegia of the left eye; right eye

has full EOMs V: Absent left corneal, seemed to not appreciate pin over left frontal-orbital

area VII-XII: IntactSensory: Withdrew all extremities equally from pinMotor: Right pronator drift; Reflexes: 3+ but slightly brisker on the right; equivocal right Babinski reflex

2. You are called to evaluate a 43 y/o female for a right ptosis. She awoke this morning with pain behind her right eye and inability to open her eye. Past history is unremarkable.

V/S: normotensive, afebrileGeneral examination: unremarkableNeuro:HIF: Intact in all spheresCoordination and Gait: normalCranial Nerves: II: Pupils 3mm equally reactive to light; right ptosis; fundi are within

normal limits III, IV, VI: Right eye rests down and out, when attempting to look

down the eye intorts, there is palsy of vertical gaze and adduction. The left eye has full range of motion.

V-XII: IntactMotor, Sensory: normalReflexes: 2+ equal and symmetric

3. A 56 y/o woman with breast adenocarcinoma metastatic to bone is found unresponsive in her hospital bed. She had been noted to be normal by the nursing staff 30 minutes previously.

V/S: BP 130/80 P 132 R 20-deep and reg. T 37.7o CGeneral examination: unremarkableNeuro:HIF: Comatose. No response to deep pain.CN: II - Fundi benignIII, IV, VI - Eyes deviated to R, occasionally drifting to midline but

returning to R; Oculocephalics - no doll's eyes; Pupils 5mm, equally reactive to light

V- R facial weaknessIX, X - NormalXII - MidlineSensory: No responseMotor: Flaccid R hemiparesisReflexes: 2+ L side. 1+ R side; toes - extensor bilaterally

4. The medical resident asks you to see a patient with hypertensive encephalopathy. The patient's wife states that while walking 2 hours previously, he developed sudden onset of severe vertigo and subsequent vomiting. He was able to walk to the subway station but lost consciousness on the train.

V/S: P 100, BP 250/120, R 36 periodic, T 38o CNeuro:HIF: Comatose, no response to deep painCN: Fundi show grade 2/4 hypertensive changes, no papilledema

Pupils: 2mm equal, sluggish reaction to lightEOMs: resting skew deviation, right above left; Oculocephalics -

absent; Oculovestibular - limited to minimal tonic deviation of both eyes to right

Corneal reflexes: intact Spontaneous vomiting with intact coughMotor: Bilateral spontaneous extensor posturingReflexes: Clonic symmetrical DTR's. Toes upgoing bilaterallyMechanical: Neck-supple except during episodes of posturingLab: EKG-Showed ST depression in all left-sided leads