Acute Neurology – Clinical
Vignettes
Ronald G. Wiley, MD, PhD
VA 873-7510
“ronald.wiley@vanderbilt.edu”
General approach
Question/answer #1: Is patient biologically
sick? (vs behavioral issues) If so, how sick? (i.e.
critically or not so serious?) Composite
opinion that requires clinical judgment.
Question/answer #2: What part of nervous
system is malfunctioning?
Functional anatomy - based primarily on
neurological exam.
Exam is an exercise in localization - first,
pathophysiology - second.
Question/answer #3: What is/are likely
etiology(s)?
Pathophysiology - based on all available
information (history, exam findings, lab), but
heavily dependent on history)
Critical issues include - precise symptoms, mode
and time of onset of symptoms, evolution of
symptoms with time, associated
symptoms/events, effects (±) of
activities/therapies on symptoms, concurrent
conditions, medications
Reading: Posner,JB, Saper,CB, Schiff,N. and
Plum,F. Diagnosis of Stupor and Coma, 2007.
1. A 26 y/o woman, previously in excellent health, complained of the worst headache in
her life which developed over a 2-3 hour period. This did not prevent her from her usual
duties, but 8 hours later (at 2:00 am) she awoke with a severe headache, nausea,
vomiting and rapidly became unresponsive.
V/S: B.P. 100/60; P 96, reg; RR 10, shallow; T 36.8o C
General medical exam is unremarkable.
Neuro: HIF (~mental status): unresponsive to verbal stimuli.
Cranial Nerves II. No response to threat; fundi-normal; pupils are 2mm and sluggishly reactive to
light.
III, IV, VI: Full EOMs to the doll's head maneuver.
V. Trace corneal response bilaterally.
VII. No grimacing.
Motor/Sensory; increased tone bilaterally; flexor posturing in upper extremities and
extensor posturing in the lower extremities to noxious stimuli bilaterally.
Reflexes; 3+ bilaterally, unsustained ankle clonus; bilateral Babinski reflexes.
She rapidly becomes apneic, requires intubation; the right pupil dilates to 6mm with the
left pupil 2mm and a left flaccid hemiplegia develops.
2. You are called to see a 58 y/o defrocked priest who has a past history of mental illness
and alcohol abuse. His admission to the medical service had been precipitated by
pulmonary complaints and he has been shown to have an adenocarcinoma of the lung for
which radiotherapy has been started the previous day.
Over the previous 48 hours he had developed progressive clouding of
consciousness.
V/S: BP 130/80; P 96; R 24; T 38o C.
Neck supple.
HIF: Mildly stuporous, but easily aroused when he assumes a crossed-leg sitting position
and scratches his head with either hand. Non-communicative save for an occasional
"yes." No spontaneous speech. No visual fixation on examiner.
Cranial Nerves Normal fundi.
Oculocephalic responses full with an occasional superadded saccadic
movement. Oculovestibular responses-nystagmus.
Corneal responses intact.
No facial asymmetry.
Motor - Hypotonic. No focal weakness. Bilateral intermittent multifocal
myoclonic twitching movements.
Symmetrical brisk DTRs. Plantar responses are extensor.
3. A 53 y/o woman is brought to the E.R. by her husband, having been found
wandering about their apartment early that morning in a confused state.
She has a past history of autoimmune thrombocytopenic purpura which had
been treated by splenectomy 2 years ago.
Current medication is prednisone 5 mg bid.
V/S: BP 120/80; P 90; R 18; T 38o C.
HIF: Neck supple. Fluctuating between lethargy and agitation. Only
vocalization was moaning and grunting in response to verbal or tactile
stimulation.
CN: Fundi normal.
Full eye movements. Blepharospasm.
No facial asymmetry.
Sensory - intact.
Motor: Paratonic. No focal weakness.
Symmetrical brisk DTRs. Plantar responses - bilateral extensor.
4. A 52 y/o black female is referred to the emergency room from her local HMO for acute
onset of vertigo, gait unsteadiness, nausea and slurred speech. In the several hours
since the symptoms began, she has also noted new onset of oscillopsia, tingling in her
left hand and mild occipital headache. She has a history of hypertension treated with
Aldoril, and 10 months earlier, she had an episode of nystagmus and horizontal diplopia.
CT and LP at that time were WNL.
V/S: BP 150/120, afebrile
WN, WD, BF in NAD.
Head and neck exam - benign.
HIF: WNL
Coordination: Decomposition of movement with slow, irregular
RAMs of left arm and leg.
Cranial Nerves Horizontal nystagmus to right in primary position which increased on right gaze
and decreased on left gaze. Rotatory component developed on vertical gaze.
Full EOMs.
Decreased light touch in right V2 and V3 and decreased pin in V3 on left.
Mildly increased palpebral fissure and lag to corner of mouth on left.
Uvula deviated to right and patient was dysarthric for all speech sounds.
Sensory: Decreased pin and light touch in hands, L & R.
Rest of Exam: WNL except for unsteady gait.
5. You are called to Triage to see a 52 y/o white male farmer for confusion and double
vision. He states that he has been feeling weak and is unable to walk. Wife reports that
her husband became acutely confused approximately 3 days before. She also states that
he slipped on a tractor the week before hitting his head; no LOC. He and his wife report
an ETOH habit of two to three beers a night. No toxin exposure reported although he
has recently finished spraying his tobacco with herbicide. He is on no meds.
V/S: BP - 100/70 without orthostatic change P-84 R-18 T-98o po
General exam - skin shows a macular hyperpigmented rash over the abdomen and
anterior thorax.
HIF - Disoriented in all spheres.
Memory - Recent & immediate recall impaired.
Calculations - can make change.
(R)-(L) orientation intact.
(-) dysnomia/agnosia.
Written constructions good; can read & write.
Gait & Station - wide base; unable to tandem.
Coordination - RAM somewhat slowed.
Cranial Nerves Bilateral 6th N. palsy (L) worse than (R).
Nystagmus in all fields of gaze; none in primary position.
Sensory - intact.
Motor - Strength 5/5 all; atrophy 1st dorsal interosseous on right.
DTRs - 2+ all except ankles = 0/0