Doctors, check your understanding?
An 82 year weak man enters your department complaining of right sided headaches and difficulty walking. These headache have be occuring for approximately 3 months and are worse at night. He also stumbles at times because of disappeared leg weakness.
His come first shows no evidence of trauma, he is alert and fluent with speech. He is knowledgeable of naming and repitition and can count down from 100 by sevens. His pupils are round and reactive to light. His ocular fields are full but next to extinction on the left to double simultatneous stimulation. His facial sensations are intact and his facial muscles move symmetrically. He shows mild vanished hemiparesis and normal right sided strength. He shows commonplace gait. His reflexes are fine except that he shows Babinski's sign contained by his left foot.
What's the differential and what do you do first?
Answers: I estimate several answerers have correct thoughts, and that the information you have presented is not anywhere practical as complete as you seem to expect it is. First, we're missing most of the basic history and physical exam, so the first entity I'd do is finish gathering that information. One knob is what his vital signs are. Is this personality stable enough that we can lug our time figuring this out or do we obligation to pick up the pace? It sounds resembling he probably is stable, but we don't know that from the information provided. Assuming we have time to seize more information, there's a lot more that would be adjectives to know about his symptoms. Are the headache the same as when they started or are they getting worse? Does anything specific end in the headaches to grasp worse? Are they present every day? Has he tried any medicine? If so, do they help at adjectives? Has he had any nausea, vomiting, or optical changes? Did he slop or hit his head on something 3 months ago when this started? You probably wouldn't see any outward evidence of minor trauma that happen 3 months ago. Is he on aspirin or other blood thinners? Has he had leg lowliness and difficulty walking for 3 months also, or is that a new finding? Is the vulnerability always present? Does he mind anything that makes it worse? What have changed that he's here now after 3 months of trouble? What's his previous medical history? Has he ever had cancer? Any heart problems or vascular disease? These are adjectives things that help direct the differential diagnosis.
What is the rest of the physical exam? A point of clarification - CSF surrounded by the ears is not part of the neurologic exam contained by that you're not assessing the function of the nervous system. And, relatives can and do survive with chronic CSF leak, though they are at increased risk for meningitis and they are treated when discovered. As someone else mentioned - is there any common sense on exam to suggest that the patient have other disease processes going on? This isn't a complete neuro exam, either. Are his extraocular muscles intact? How's his audible range? There is no mention of his cerebellar function except mentioning a normal gait, which isn't exactly consistent near the brief history that's presented. This would be important to assess within someone with difficulty walking, as the cerebellum coordinates movement. How did we agree on that he stumbles because of weakness? When you read aloud he has mild disappeared hemiparesis, what do you mean exactly? Is it the entire moved out side equally? How severe is this weakness? Are some places more involved than others? What's his muscle tone similar to? Is he flaccid, spastic, or normal? Another clarification almost the exam is that he doesn't really have any signs of elevated intracranial pressure, aside from headache, but in that are many more adjectives reasons for headache than elevated ICP. He have no pupillary changes and apparently no history of ocular changes, nausea or vomiting, which would be more indicative of elevated ICP.
And so on. A common learning is that the most important entry for making a good diagnosis is a thorough history, which is short in this example. The subsequent thing is a thorough physical exam, which is also underprovided here. Then come studies, which you order base on the history and physical in an attempt to shrink down your differential. With the information presented, the differential is very broad, and we're forced to be broad contained by our approach, ruling out the things that need to be address most urgently. Using the neurologic exam to localize the lesion, it would seem that he imagined has something surrounded by the right cerebral hemisphere. Upgoing toes suggest an upper motor neuron lesion, which funds spinal cord or brain. The presence of visual symptoms make the brain more likely and the left-sided symptoms would indicate a right-sided lesion. There are several possibilities, next to some of them being a chronic subdural hematoma (often no inciting trauma given by history, could involve life-size areas of cortex), some kind of mass lesion, any a primary tumor or multiple metastatic lesions (why it would be long-suffering to know his medical history), some kind of infectious process near intracerebral abscesses (again medical history - is he immunocompromised?), complex migraines (more characterization of the headache would be nice), or even seizures near post-ictal changes, and that's newly a start. The first thing I would do is command a non-contrasted head CT as resourcefully as some basic labs, including a unfinished metabolic panel, complete blood count, PT/INR, PTT, and type and screen/cross for blood products, getting the patient prepared to go to the OR if he wants to go. I'd also build sure he isn't eating anything. I'd carry the non-contrasted head CT to evaluate for the presence of intracranial blood, which is possible and the one item that comes to mind that would prompt more urgent surgical intervention. If something other than a hematoma is identified, further imaging (MRI) can be ordered at that point for better characterization of those lesion and to develop a plan. It's really difficult to give a more definitive answer near incomplete information.
I think he have TIA's or mini strokes.
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