16.4 – Nervous Systems Diseases, Disorders and Diagnostic Testing

Use the words below to fill in the history and physical examination form:

• festination
• depression
• fatigue
• postural
• rigidity
• cognition
• downgoing
• q.i.d

PATIENT NAME: Susan LOGAN
AGE: 62
SEX: Female
DOB: March 24
DATE OF ASSESSMENT: December 10
ADMITTING PHYSICIAN: Martin Lewis, MD, Neurology

DIAGNOSIS: Parkinson disease

HISTORY: This pleasant and co-operative 62-year-old woman has advanced parkinsonism which presents for more than 10 years. It is affecting her daily living to a great degree. She has minor difficulty with ADLs noted in difficulty dressing and meal preparation. She has had frequent falls occasionally related to freezing or to _______[Blank 1] but also occurring without any apparent cause. She has marked hesitancy on changing direction and unsteadiness after exertion and develops _______[Blank 2]. She has a minor problem with sialorrhea, eating, and swallowing. She can maintain basic personal hygiene without any difficulty. However, showering or bathing requires assistance. She has had some symptoms of anxiety and ________[Blank 3] along with her Parkinson disease.

PHYSICAL EXAMINATION: On neurologic exam, she did have mild-to-moderate impairment in _________[Blank 4] and short-time memory, although she is alert and oriented x3. She has pronounced tremor, worse in the left arm than the right. She has marked ________[Blank 5] in the upper left extremity; mild in the right. She has marked reduction of movement with long delays in initiating movement and frequent freezing. She has a moderately-flexed posture and cannot straighten to command. She has __________[Blank 6] instability. Her speech is mildly dysarthric. She has paucity of spontaneous facial expression. She has an unsteady and erratic gait characterized by shuffling strides with festination in propulsion. She can arise from a chair with difficulty only after multiple attempts. Deep tendon reflexes (DTRs) are symmetrical, and toes are __________[Blank 7]. Cranial nerves are intact and unremarkable.

TREATMENT AND PLAN: She has been on Sinemet 25/100 t.i.d. for the last 7 years or so. She will be going on vacation soon, and I do not wish to start a second antiparkinsonian medication while she away from medical supervision. However, I have asked her to increase her Sinemet dose to _______[Blank 8]. We will see how she does with Sinemet and plan to add bromocriptine 1 mg per day when she returns.

FOLLOW UP: The patient has been scheduled for follow up in 3 weeks, upon her return from vacation. Her treatment regimen will be adjusted at that time.

________________________
Martin Lewis, MD, Neurology

Check your answers: ^[1]

Use the word below to fill in the consultation report:

• cognition
• dementia
• hypertension
• downgoing
• neurological
• symptomatic
• MRI
• stroke
• blurred

NEUROLOGICAL SYSTEM – CONSULTATION REPORT
PATIENT NAME: Robert BROWN
AGE: 74
SEX: Male
DOB: July 5
DATE OF CONSULTATION: April 15
CONSULTING PHYSICIAN: Martin Lewis, MD, Neurology

REASON FOR CONSULTATION: Assessment of cognitive changes and testing.

HISTORY: The patient presented a few days ago with a marked change in __________[Blank 1] identified by his family members and care staff. The reports describe two episodes of the patient presenting a somewhat confused state, instability with a “holding of the temples” and a report of blurring vision. The patient was also observed holding on to walls and furniture to walk around. This seems to have been two transient episodes and has not recurred since. Prior to that, he had maintained excellent cognitive abilities with full lingual ability, no signs of aphasia, __________[Blank 2] or loss of consciousness. The cognitive decline noticed was not of gradual onset but rather an acute change within hours to a day. The time span is unclear as the patient lives alone and there was a time lapse between a family visit and the arrival of a personal care assistant.

The patient is a good historian to questioning and does admit to some recent occasional headaches and ___________[Blank 3] vision. These are new to him as he reports never having “had a headache” in his “whole life”. He reports that the blurring is not constant but only seems to occur when he turns his head to right or left suddenly. There is a “tilting sensation” like he will fall but this clears when he brings his head back to center. He has no history of epilepsy or seizure disorders. No history of TM or ear trauma.

PHYSICAL EXAMINATION: HEENT: Head is normocephalic. EYES: PERRLA. EARS: Auditory exam reveals intact TMs bilaterally. No erythema. The nose and throat exam is unremarkable. NECK: JVD appears normal. VITAL SIGNS: Blood pressure is 132/86 with no previous history of ____________[Blank 4]. Pulse is 83 and resp. 22 but the patient does admit to feeling anxious during the assessment. Temperature 37C.

NEURO: Orientation and language are normal. Extremity strength testing show some minimal weakness in the right upper. Reflexes are normal. Toes are ___________[Blank 5] bilaterally. Has difficulty with heel-and toe-walk and is unable to tandem walk. The gait is alternately normal and minimally spastic.

IMPRESSION: What appears to be a transient or acute cognitive change with altered awareness, headache and cephalo-positional blurring of vision. There is some ____________[Blank 6] change, although minimal and not clinically diagnostic, as evidenced by the slight changes in gait during testing but it does not remain consistently. This is puzzling.

PLAN: It is still not clear to me what these spells are. Some of the neurological possibilities to be considered are TIA, __________[Blank 7], brain and spinal cord tumors, inflammation, infection, vascular irregularities, and some neurodegenerative disorders. I have ordered a stat cerebral _________[Blank 8], electroencephalogram (EEG) and blood levels for CBC, chem panel. However, I feel we should also rule out the more common possibilities of pseudo-seizure, vertigo, and inner ear anomalies and am in the process of making these appropriate bookings.

I have booked a follow up with this patient in 10 days to review the results. He and his family have been advised to contact me immediately if he has another “spell” or to present to the ER where we can complete testing when the patient is ____________[Blank 9].

Thank you for this most interesting referral. I will be in touch after I have reviewed the patient.

_________________________
Martin Lewis, MD, Neurology

Check your answers: ^[2]

Use the words below to fill in the follow-up report:

• electroencephalogram
• balance
• pathology
• vertigo
• coordination
• white matter
• hemorrhagic
• wasting
• calcifications
• mass
• somnolence
• symptomatic

PATIENT NAME: Randy NORTON
AGE: 74
SEX: Male
DOB: October 14
DATE OF ASSESSMENT: January 18
ASSESSING PHYSICIAN: Martin Lewis, MD, Neurology

REASON FOR ASSESSMENT: Follow up assessment of cognitive changes and testing.

HISTORY: This 74-year-old patient was seen in consultation 10 days ago for assessment of cognitive changes. He underwent prescribed testing in the forms of cerebral MRI, _____________[Blank 1] (EEG) and blood was drawn for CBC and chem panel. The patient was seen by our local ENT for inner ear and __________[Blank 2] testing. Test results showed normal hearing. No evidence of an inner ear __________[Blank 3] that might have contributed to the __________[Blank 4] or lack of balance and _____________[Blank 5] reported as part of the presenting symptoms.

TEST RESULTS: Cerebral MRI reveals a few T2 hyperintensities in the ____________[Blank 6] in the left temporal lobe. The right hemisphere shows some diffuse ___________[Blank 7] and some occipital wasting. There are multiple, small dark ____________[Blank 8] areas and a few areas indicative of ischemia.

EEG: This showed some depressive effect indicative of an encephalopathy. The patient did not sleep during the exam but did show some signs of ___________[Blank 9]. CBC and chem panels were normal.

IMPRESSIONS: This patient present with testing result that may be warning for Alzheimer wasting and also, some localized hemorrhagic events that have since stopped. This type of “leakage” is often not ____________[Blank 10], and I do not feel that they are connected to his presenting complaints. I see no signs of tumor or __________[Blank 11] formation nor infectious process.

On repeat verbal assessment, the patient reports he has not experienced any more of the spells. We will follow him closely in regards to the ____________[Blank 1]2 with a repeat MRI and perhaps a CT also in 3 months for results comparison to see whether the wasting has advanced or receded.

Thank you for asking me in on this most interesting case.

_________________________
Martin Lewis, MD, Neurology

Check your answers: ^[3]