CRITICAL THINKING SCENARIO: DIAGNOSE THE PATIENT A 30-year-old female comes to you with complaints of occasional tingling and numbness throughout her upper and lower extremities. She has been experiencing this over the last 6 months. She has recently experienced double vision and noticed she was getting weaker. She has been under extreme emotional stress lately. Initial Examination Vitals | Patient | Reference Range Pulse ox | 96% | > 95% Respiratory rate | 17 bpm | 12 to 20bpm Blood pressure | 118/70 mm/Hg | < 120/ <80 mm Hg Heart rate | 70 bpm | 60–100 bpm Physical Examination Skin appearance: normal Neurological Examination Elevated reflexes Pupillary symmetrical in response to light Muscle Strength Testing Both upper and lower extremities demonstrate global weakness 1. Which of the diagnoses fits this patient’s clinical presentation? Explain why the others are not the correct diagnosis. a. The patient is having a cerebral vascular accident. (Stroke) b. Herniated disc at the level of the upper cervical spine c. Multiple sclerosis (Autoimmune disease of the central nervous system)
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A 54-year-old right-handed female consulted a neurologist for complaints of numbness in her feet for the past two weeks with "pockets" of numbness in the abdomen. Her legs feel heavy and numb. Her hands started tingling a week ago, and she is feeling very nervous. She has had similar episodes over the past three (3) years, lasting about a week at a time, often after stressful events or during hot weather. She states that at times her vision is blurred. PMH: No operations/no serious illnesses/accidents Father: age 71, L & W; Mother, age 66, is bipolar Her only sibling, a sister, age 28, has cerebral palsy. SH (social history): denies smoking or use of street drugs, drinks socially OH (occupational history): certified public accountant. Marital status: married ROS: non-contributory VS: T 98.2°F, P 82 and regular, R 16, B/P 110/68, Ht 5'3", Wt. 140 lbs. PE: HEENT: WNL. Neck: negative, heart/lungs: normal Cranial nerves intact. Reflexes: DTRs are increased, greater on the right without spasticity. There is numbness to tactile pin stimulation over both extremities. She demonstrates ataxia. Dx: R/O MS (Rule out Multiple Sclerosis) Plan: Schedule MRI of the brain with and without contrast. Describe the test the patient is scheduled to have. It is a scan produced by magnetic fields and radio frequency waves.
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A 71-year-old woman was referred to the neurologist with 10 months of progressive gait difficulty, right leg numbness, and urinary problems. The patient was in good health, walking 3-4miles per day until about 10 months prior to admission, when she first noticed her mild gait unsteadiness and bilateral leg stiffness. She felt her feet were not fully under control. Her left leg gradually became weaker than her right, with occasional left leg buckling when she walked. Meanwhile her right leg developed progressive numbness and tingling, and she had intermittent left-sided thoracic back pain. Finally, she had increased urinary frequency, occasional urinary incontinence and difficulty completing a bowel movement despite several laxatives. Physical test: unremarkable apart from her rectal sphincter could not voluntarily contract. Neurologic test: Alert and oriented, mildly anxious but otherwise normal. Cranial nerves tested without any abnormalities Motor test of the upper extremities unremarkable. Lower extremities: normal muscle mass, tone increased in left leg, 5/5 strength throughout except for 4/5 in the left iliopsoas muscle. Reflexes are increased in the left leg, positive Babinski sign. Gait – Stiff-legged and unsteady Sensory test showed decreased pinprick sensation on the right side below the umbilicus. Vibration and joint position decreased on the left foot and leg. Otherwise, intact. Explain the anatomy and pathophysiology of the key symptoms listed below. Briefly describe the main pathways/tracts affected and their function (24 marks total) left leg weakness, increased tone, hyperreflexia, and Babinski’s sign (4 marks) decreased vibration and joint position sense in the left foot and leg (4 marks) decreased pinprick sensation on the right side below umbilicus, with right leg numb, tingling paraesthesia (4 marks) left-sided thoracic back pain level (4 marks) stiff-legged unsteady gait (4 marks) impaired bowel and bladder function (4 marks) What is the condition? Locate the lesion (3 marks) Suggest three possible causes (3 marks total, 1 mark for each suggestion)
Clinical Case Study: A 30-year-old female has had several episodes, each separated by several months, in which she experiences brief periods of physical weakness, clumsiness of the legs and hands, visual disturbances, and mood swings. Her weakness is most prominent in her lower extremities. CT scans show evidence of multiple lesions in the white matter of the brain and spinal cord. During her last episode, there were increasing neurological deficits due to an increasing number of disseminated lesions. Prednisone (60 mg/day for five to seven days) was prescribed and helped her return to as normal and active a life as possible. Discussion Questions: 1. How is the process of myelination different between the CNS and the PNS? 2. What type of cells do you think are being affected with this patient: oligodendrocytes, Schwann cells, or both? 3. What type of tissue or cells of the nervous system are being affected by the treatment medication Prednisone? Explain how the drug is alleviating her neurological symptoms. 4. What do you think is the official diagnosis of this particular patient? 5. What other similar diseases or disorders can you reference as another example of a myelination issue or tissue level issues of the nervous system? Include what specific cells/tissues are being affected histologically from chapter 12.
Shyam P.
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