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Slide 1 :

Neurology Rounds: Case of Mr. M.V. January 24, 2008 Dr. Florence Morriello Queen’s University

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Initial Presentation ID: Mr V: 36 y.o. right-handed M CC: severe headache and problem moving right side HPI: found by neighbour wandering in neighbourhood “confused” and with right-sided weakness EMS called and was brought to Brockville General Hospital

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Initial P/E in Brockville: Vitals: BP 120/84; HR 85 reg; RR=16; afebrile CVS: Normal, no carotid bruits bil. Resp: Normal Exam complicated by deafness - did not have hearing aid Confused - not oriented to time or place. Unable to follow basic commands even when written Right-sided weakness

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Initial Neurological Examination Brockville MSE: Language: Word-finding difficulties CN I-XII were normal. Normal EOM, no nystagmus on lateral gaze. PERL. Motor Exam: normal muscle mass and symmetrical, no abnormal mvts. Normal tone throughout UE/LE bil. Power 5/5 L and R side not able to move R arm and leg except by lifting his sleeve with left side (intact). Reflexes normal UE/LE bil. Babinski was flexor bilaterally

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Initial Neuro Exam Brockville Sensory Exam: Normal Coordination: unable to perform all testing. Ataxic Gait: Not assessed

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INVESTIGATIONS Bld work - CBC, lytes, glucose, coag’s, LFT’s and tox screen were negative. Urinalysis neg. Anion-gap normal. CT head showed ischemic stroke Admitted Brockville overnight and started on ECASA and Clopidogrel. Arrangements made to transfer to KGH for further workup.

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Presentation on Arrival to KGH: Additional HPI: Collateral from aunt & uncle - baseline speech fluent & no difficulty with naming Complained of h/a, localized behind ‘ears’ but when asked to point, pointed to eyes Aware that day prior had difficulties dressing himself and was helped by neighbour

Slide 8 :

PMHx: Adjustment Disorder - past abuse stressors (Dx. 2005) Past Dx of Schizophrenia (no meds) Bilateral Deafness—wears a hearing aid Viral Meningitis as a child (1983) Chronic h/a (seen by Dr. Dinsdale 1996--probably psychogenic) Chronic Back Pain – KGH Aug. 2007 for mech back pain & fever NYD—MRI showed mild degenerative disc disease in L5-S1 region. Discharged on Flexeril

Slide 9 :

Social History Lives alone in Brockville On Ontario Disability Support Progam A smoker with a 25 pack year history Non-alcohol drinker. No illicit drug use.

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90 79 MI in 70’s ?mesothioloma 61 61 63 58 Hearing impaired PE in 30s Severe pre-eclampsia Severe HTN Died of stroke 36 32 MI @ 34 Hearing impaired Hearing impaired Ischemic gut @ 48 Stroke @ 61 Stroke @ 62 36 31 Hearing loss as Teenager Proteinuria Significant weight loss 28 21 Family Pedigree

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Physical Examination KGH: No skin changes, no evidence of angiokeratomas, telangiectasias CVS: N heart sounds, no murmurs, no carotid bruits Resp: no adventious sounds

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Neurological Examination KGH: A & O to name and place but not date. MSE: Language: comprehension difficulty probably due to hearing loss, Difficulty following commands, Difficulty naming objects, Paraphasic errors Unable to repeat phrases, unable to read label of tissue box Apraxia CN I-XII no impairments; PERL, no nystagmus on lateral gaze.

Slide 13 :

MOTOR Examination: Normal muscle bulk, symmetry, no abnormal involuntary mvts. Normal muscle tone No pronator drift Power 5/5 in both UE and LE Reflexes: DTR 2+ UE/LE bil, no primitive reflexes

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SENSORY Examination: PRIMARY: Normal pain/temperature sensation Normal proprioception/vibration sense

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COORDINATION/GAIT BALANCE: Coordination: unable to follow commands to perform tests GAIT: slightly wide based

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INVESTIGATIONS?

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CT-Head w & w/o contrast:

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Investigations: CT head w & w/o contrast: Multiple cortical infarcts of differing ages including acute on subacute L MCA infarcts and chronic right lateral temporal cortical infarct. CT angiography: no signif. stenosis, filling defect or vascular dissection Hyperintensity and calcification of the pulvinar nuclei bilaterally. MRI Brain: PENDING

Slide 23 :

Investigations: Labs: 24 Hr Urine Protein Alb Hgb 147, WBC 12.4, differential N 8.3, L 2.9, Plt 310, Cr 60, BUN 3.5, Na 137, K 4.0, Cl 102, ESR 17, CRP 14.5 TSH 4.16, PTH 2.7, Fasting Lipid Profile

Slide 24 :

Investigations: Prothrombotic Work Up: Protein C 1.09, Antithrombin 1.07, Protein S PENDING, Homocysteine PENDING, Antiphospholipid Abs PENDING, Prothrombin gene mutation PENDING Alpha-galactosidase activity PENDING HIV PENDING

Slide 25 :

Investigations: ECG—NSR Transthoracic Echocardiogram: EF60%, normal size and systolic function of LV. Mitral Valve minor leaflet thickening of anterior leaflet. Seen from one imaging plane only. F/U TEE

Slide 26 :

Medications changes by KGH After Assessment: Clopidogrel 75 mg od Metoprolol 12.5 mg bid Nicotine Patch 21 mg top od Colace 100 mg bid

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