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Case Study QT
CC: LEFT arm numbnessHPIQT 59 yo RH maleJuly 2014;20 minute episode of
Left arm dangling and “unable to wink” left eye; symptoms resolved after 20 minutes
Case Study QT
CT showed cerebral lesions concerning for metastatic disease; unable to fit in MRI scanner at hospital. Open Scanner showed 3 cm wedge shaped transcortical T2/FLAIR hyperintensity in the posterior RIGHT occipital region with diffusion restriction; plus a minimum of 5 more, smaller areas in the RIGHT frontal and parietal lobes
Nonadherent with warfarin, started on Xarelto
Case Study QT
2nd admission 9/18 after awakening with left arm numbness
3rd admission 1/19; left arm numbness while lying in bed watching TV; no other associated symptoms; resolved after 2 minutes
Recurrent symptoms during the hospital admission while sitting in a chair
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Case Study QT
Carotid Ultrasound 1/20 revealed elevated velocities in the Left ICA; estimated 50-70% narrowing and no apparent flow in the RIGHT ICA seen on CTA in September. REPEAT CTA on 1/21 occluded RICA and 50-60% LICA stenosis
Case Study QT
Past Medical History:HTN, Hyperlipidemia,
Pneumonia, Afib, Tobacco addiction, Morbid obesity
Past Surgical History:LEFT carotid endarterectomy
Sept 2014
Case Study QT
Social History:Truck DriverMarried2-4 alcoholic Beverages daily½ pack of cigarettes daily
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Case Study QT
MedicationsAtorvastatin 20mg dailyMetoprolol 50mg twice dailyXarelto 20mg dailyAspirin 325mg dailyTribenzor 20-5-12.5mg daily
Case Study QT
Review of Systems:Negative
Case Study QT
Physical Exam BP 110/70, Pulse 74 Height 5’7”
Weight 291 Pounds BMI: 45.58General Appearance Alert, well, no distress, morbidly obese No carotid bruits bilaterally Oropharynx; Mallampati class 4 Airway Apical regular without R/M/G Peripheral Circulation: Normal by
inspection
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QT Case Study
Neurologic Exam Mental Status:Alertness and orientation to time,
place and self: Normal. Recent and remote Memory: Normal. Attention & Concentration: Normal. Language: Normal. Fund of knowledge: Normal.
QT Case Study
CN II: Left lower quadrantopsia, extinguished LEFT VF to DSS
III, IV & VI: Extraocular movements Normal
V: Facial Sensation NormalVII: Facial strength NormalVIII: Hearing intact to finger rub
bilaterally, no nystagmus
QT Case Study
IX, X: Palate midlineXI: Trapezius and
Sternocleidomastoid Muscles 5/5XII: Tongue midline
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QT Case Study
Motor ExamStrength of the upper and lower
extremities were 5/5 all groups. Normal Bulk and Tone. No pronator drift. No abnormal movements were seen.
Reflexes: Deep tendon reflexes were symmetrical and normal. Plantars were flexor bilaterally
QT Case Study
Sensory: Intact to light touch temperature and vibration. Pinprick was decreased in digits 1-3 bilaterally.
Cerebellum: No impairment of finger to nose or heel to knee to shin bilaterally.
Balance: Normal
QT Case Study
Gait & Station: Base; Narrow. Able to heel, toe and tandem without difficulty. Arm swing was decreased on the LEFT.
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QT Case Study
What other physical exam testing should be
done?
Tinel’s Testing and/or Phalen’s sign
QT Case Study
Impression:RIGHT Posterior Temporal infarction
with at least 5 Right sided additional embolic small areas of infarct in the setting of Afib in July 2014
Mallampati Class 4 airway, Epworth Sleepiness scale Score 16, morbid obesity, snoring, recent stroke; suspect sleep apnea
QT Case StudyImpression:4 episodes of left arm numbness
7/2014, 9/18, 1/19 and 1/22. Positive Tinel’s signs at left elbow and both wrists; suspect carpal tunnel syndrome & left cubital tunnel syndrome
Left lower quadrantopsia and extinguishment of LEFT VF with DSS
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QT Case StudyPLAN:1. Continue Xarelto
(nonadherent with Coumadin)2.Sleep eval3. Lifestyle Modification for risk
factor mitigation: Smoking cessation, weight loss, exercise
4. NCV for Carpal Tunnel/Wrist Splints
QT Case Study
Electrodiagnostic testing was abnormal.
There was evidence of moderately sever entrapment of the right and left median nerves at the wrists (bilateral carpal tunnel syndrome).
QT Case Study
At follow up, Mr. QT reported no symptoms of carpal tunnel since wearing wrist splints.
No further ER visits!
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Case Study SM
CC: Small handwriting and decreased facial expression
HPISM 70yo RH femaleShe reported small handwriting for several months and friends have commented that she seems depressed
SM Case Study
Denies drooling, choking or difficulty swallowing
Denies falls Denies hallucinationsCan turn over in bed without
difficultyNo trouble with fine motor skillsDenies any slowness with eating,
bathing or dressing
SM Case Study
PMH:HTN, Stage I Gastric Lymphoma 2 years prior (in remission); hypothyroidism, diverticulosis, subclavian DVT, RIGHT rotator cuff tear, disseminated herpes zoster, sepsis, thrombocytopenia,
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SM Case Study
PMH cont’dSubarachnoid hemorrhage,
hyponatremia, Uncontrolled atrial fibrillation,
SM Case Study
MEDICATIONSMetoclopramide (Reglan) 10MG
3 times dailyLabetalol 200mg twice dailyZofran 8mg 3x per day Coumadin 2mg daily
SM Case Study
SOCIAL HISTORYEmployed full timeNo tobacco or ethanolNever married
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SM Case Study
Review of SystemsPositive for:Projectile vomiting, diarrhea
SM Case Study
PHYSICAL EXAMBP 112/80 Apical 76
General AppearanceAlert, well, no distress, masked faciesNo carotid bruits bilaterallyApical regular without R/M/GPeripheral Circulation: Normal by inspection
SM Case Study
Neurologic Exam Mental Status:Alertness and orientation to time,
place and self: Normal. Recent and remote Memory: Normal. Attention & Concentration: Normal. Language: Normal. Fund of knowledge: Normal.
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SM Case Study
CN II: VF Full III, IV & VI: Extraocular movements
NormalV: Facial Sensation NormalVII: Facial strength NormalVIII: Hearing intact to finger rub
bilaterally, no nystagmus
SM Case Study
IX, X: Palate midlineXI: Trapezius and
Sternocleidomastoid Muscles 5/5XII: Tongue midline
SM Case Study
Motor ExamStrength of the upper and lower
extremities were 5/5 all groups. Normal Bulk.
Tone increased most notably in the LEFT upper extremity. Cogwheeling rigidity bilaterally at the wrists and elbows. There was also cogwheeling at the LEFT ankle.
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SM Case Study
No pronator drift. No abnormal movements were seen.
Reflexes: Deep tendon reflexes were symmetrical and normal. Plantars were flexor bilaterally
SM Case Study
Sensory: Intact to light touch, temperature, pinprick and vibration.
Cerebellum: No impairment of finger to nose or heel to knee to shin bilaterally.
Balance: Normal
SM Case Study
GAIT & STATION:She was able to rise from a chair
without using her arms. Gait was slow, stride shortened. There was decreased arm swing. There was no retropulsion. She was bradykinetic
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SM Case Study
Drawing of a spiral revealed sticking.
Handwriting was micrographic.
Motor Exam -Tremor
SM Case Study
IMPRESSION:Secondary parkinsonism due to Metoclopramide (Reglan)
PLAN: Discuss tapering Metoclopramide with Gastroenterologist
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SM Case Study
Follow up 3 months later, ALL secondary parkinsonism symptoms had resolved after metoclopramide was discontinued.
M. Emory Case Study
CC: Memory loss; 2nd opinionHPI: 86 RH femaleAccompanied by her husbandStory was NOT sequential and
difficult to followME stated “I feel dizzy, like my
head and feet are not connected.”
M. Emory Case Study
Husband stated ”she says I got to tell you something…..”–Word finding difficulty –Cannot finish her thought–Trouble balancing checkbook–Repeats questions–Spends excessive amount of time talking about plans
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M. Emory Case Study
Takes longer to complete tasksPersonality change; more
argumentativeRecipes the same, “meals not as
good”Initiates bathing and clothing
change
M. Emory Case Study
Prior Evaluation/Review of DataCT head without contrast: No
acute intracranial processCBC & CMP unremarkableStarted on Aricept, developed
bradycardia and syncope, fell, was hospitalized. Aricept discontinued. Namneda started
M. Emory Case Study
Past Medical History:Hypertension, neuropathy,
osteoarthritis, hyperlipidemia, history of atrial fibrillationPast Surgical HistoryBilateral cataract surgery 7 years prior
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M. Emory Case Study
Family History:Mother deceased from stroke,
neuropathyFather deceased from stroke,
heart disease
M. Emory Case StudySocial History:
Lives with husband/Married 52 years
Retired remedial math and Grades 1-3 teacher
Etoh: 8 ounces of red wine daily
No Tobacco
M. Emory Case Study
Medications–Atenolol 25mg ½ tab twice daily
–Caltrate 600+d 1 three times daily
–Fish oil 1000mg (2) twice daily–Gabapentin 300mg (2) three times daily
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M. Emory Case Study
Medications–Kristalose 20GM as needed–Voltaren 1% Gel–Warfarin 2.5 mg tabs; dose based on INR
M. Emory Case Study
Review of SystemsPositive for:Irregular heart beat,
constipation, joint pain, loss of balance, sinus problems related to allergies
M. Emory Case Study
PHYSICAL EXAM BP 122/58 Apical 72
Ht. 5’8” Wt. 190# BMI 28.89General AppearanceAlert, well, no distress, Well groomed.No carotid bruits bilaterallyApical regular without R/M/GPeripheral Circulation: Normal by inspection
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M. Emory Case Study
Neurologic Exam Mental Status: MMSE was 29/30. One point was lost for
short term recall. She drew a clock and placed the hands so the time demonstrated 11:10 without difficulty.
She was tangential, pleasant and cooperative.
M. Emory Case Study
Funduscopic exam without evidence of hemorrhages, exudate or papilledema.CN II: VF Full III, IV & VI: Extraocular movements
NormalV: Facial Sensation NormalVII: Facial strength NormalVIII: Hearing intact to finger rub
bilaterally, no nystagmus
M. Emory Case Study
IX, X: Palate midlineXI: Trapezius and
Sternocleidomastoid Muscles 5/5XII: Tongue midline
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M. Emory Case Study
Motor ExamStrength of the upper extremities
was 5/5 EXCEPT decreased range of motion and strength RIGHT shoulder. All groups in the lower extremities were 5/5. Normal Bulk.
Normal bulk and Tone.
M. Emory Case Study
No pronator drift. No abnormal movements were seen.
Reflexes: Deep tendon reflexes were 1+/4 and symmetrical. Plantars were flexor bilaterally.
No forced hand grasping or palmomental sign
M. Emory Case Study
Sensory: Intact to light touch temperature and vibration.
Cerebellum: No impairment of finger to nose or heel to knee to shin bilaterally.
Balance: Normal
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M. Emory Case Study
Gait & Station: Base; Narrow. Able to heel, toe and tandem without difficulty.
M. Emory Case Study
KEY Question:
When did you first notice the symptoms:
M. Emory Case Study
Answer:
“After she fell on February 5 in Florida”
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M. Emory Case Study
Impression:Sudden onset of a constellation
of symptoms which include: decreased memory, impaired concentration, word finding issues, irritability and dizziness following a fall on 2/5.
M. Emory Case Study
The sudden onset of her symptoms following a fall with a head injury leads me to the diagnosis of postconcussive syndrome. Dementia is NOT sudden onset; therefore making this diagnosis less likely.
M. Emory Case Study
PLAN:MRI of Brain with and without
contrast evaluate for structural lesion
EEGCBC, CMP, B12, Folate, Free T4,
TSH and Vitamin D
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M. Emory Case Study
Physical therapy for gait training safety and balance.
Keep previously scheduled appointment with ortho for RUE
M. Emory Case Study
Follow Up 1 month later:MRI was completed and
compared with a prior MRI from 2003.Impression read: No acute intracranial abnormality, hemorrhage or mass. Cerebral atrophy and some temporal lobe predominance and mild progression compared to August 2003.
M. Emory Case Study
EEG was normalB12 386 Folate 17.2TSH 1.13 and Vitamin D 37.5Dizziness resolved, some
lingering trouble with recall (names). No longer argumentative “no cooking boo boos”.
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M. Emory Case Study
80% of baselineNamenda tapered and stopped
Follow Up 3 months later“Either at baseline or close to it”
Hedy Ache Case Study
CC: Right sided headache for 3 months
HPI: 91 RH femaleAccompanied by her daughterVague head discomfort, does not
like the word “pain” started in December (seen 3/16)
Hedy Ache Case Study
Characterizes symptom as “vague discomfort”
Points to RIGHT parietal region to indicate that is where the pain started.
Pain radiates forward to right temporal area.
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Hedy Ache Case Study
Pain is intermittentAbsent more than present“Feels like thumb tacks are being
pushed in to my head”Duration of discomfort is a few
secondsSeveral “flashes of pain” in a row
Hedy Ache Case Study
Can be pain free for hours or days
When discomfort MOST bothersome was occurring 5-6 times per day.
Severity 0.5/0-10.
Hedy Ache Case Study
No triggering eventDenies neck painNo visual loss, but vision is
blurry, has macular degenerationDenies jaw claudication
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Hedy Ache Case Study
Reports symptoms in January to PCP
PCP refers to rheumatology for suspicion of temporal arteritis
CRP 1/25 was 2.8 (0-4.9)2/6 starts Prednisone 30mg daily
Hedy Ache Case Study
February 10, temporal artery biopsy “No arteritis identified”
Remained on Prednisone 40mg daily until 3/13 with taper started.
When I saw her she was on 30mg.
Hedy Ache Case Study
One year prior used a walker intermittently
Since starting prednisone, using walker constantly
“feels like limp noodle”Sense of generalized weakness
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Hedy Ache Case Study
Past Medical History:Atrial Fibrillation, COPD,
Alopecia,Past Surgical History:Tonsillectomy age 4,
Appendectomy age 17, hysterectomy in her 70s, bilateral cataract surgery
Hedy Ache Case Study
Family History: Non-contributorySocial History: Lives with daughterDenies tobacco, social ethanol
Hedy Ache Case Study
Medications:Zetia 10mg dailyErgocalciferol 50,000 units
weeklyPrednisone 40mg dailyIron 25mg dailyOmeprazole 40mg daily
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Hedy Ache Case Study
MedicationsMetoprolol 25mg ER (2) tabs
dailyCoumadinBiotin 5000mcg dailyAzor 5-20 1 tab dailyLevothyroxine 88mcg daily
Hedy Ache Case Study
Review of Systems:Negative!Pertinent Negatives
–Denied fever, visual changes or weight loss
Hedy Ache Case Study
Physical Exam122/60 Pulse 100 Weight 114
pounds, Height 58 inches, BMI: 23.82
General AppearanceAlert, well, no distress, Well
groomed. Appears younger than stated age. Temporal arteries nontender to palpation
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Hedy Ache Case Study
No carotid bruits bilaterallyApical irregularly irregular without
R/M/GPeripheral Circulation: Normal by
inspection
Hedy Ache Case Study
Neurologic ExamMental Status:Alertness and orientation to
time, place and self: Normal. Recent and remote Memory: Normal. Attention & Concentration: Normal. Language: Normal. Fund of knowledge: Normal
Hedy Ache Case Study
Funduscopic exam without evidence of hemorrhages, exudate or papilledema. CN II: VF Full III, IV & VI: Extraocular movements
Normal V: Facial Sensation Normal VII: Facial strength Normal VIII: Hearing intact to finger rub
bilaterally, no nystagmus
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Hedy Ache Case Study
IX, X: Palate midlineXI: Trapezius and
Sternocleidomastoid Muscles 5/5XII: Tongue midline
Hedy Ache Case Study
Motor ExamStrength of the upper
extremities was 5/5 proximally and distally in all groups in the upper and lower extremities were 5/5. Normal Bulk.
Normal bulk and Tone
Hedy Ache Case Study
No pronator drift. Subtle postural and kinetic
tremorReflexes: Deep tendon reflexes
were 2/4 and symmetrical. Plantars were flexor bilaterally.
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Hedy Ache Case Study
Sensory: Intact to light touch temperature and vibration..
Cerebellum: No impairment of finger to nose or heel to knee to shin bilaterally.
Balance: Unsteady
Hedy Ache Case Study
Gait & Station: Unable to rise from a chair without
using her arms.Base; Narrow. Gait was assessed
without her walker. Stride was shortened. Required contact guard for heel, toe and tandem gait walking.
Romberg: Negative; sway, but no fall
Hedy Ache Case Study
Impression:Occipital Neuralgia1. MRI Brain with & without
contrast eval for structural lesion in the setting of new onset headache.2. Start gabapentin 100mg and
titrate to 100mg 3 times daily
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Hedy Ache Case Study
ImpressionCorticosteroid myopathy1. Check ESR, CRP, CPK,
Aldolase, LDH2. Taper prednisone per
rheumatology
Hedy Ache Case Study
Impression:Abnormal Gait1. Physical therapy for gait
training, safety, balance and endurance.
Hedy Ache Case Study
Temporal Arteritis Double vision or
sudden, permanent loss of vision
Throbbing headache in the temples
Fatigue, Weakness Temporal artery
tenderness Jaw Pain Fever Weight loss
Occipital Neuralgia Characterized by
piercing, throbbing or electric shock like pain in the upper neck, back of head and behind the ear.
Typically the pain is on one side of the head.