High Yield Neuro Clinical Vignette

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

MudPhud20XX

Full Member
10+ Year Member
Joined
Nov 26, 2013
Messages
1,349
Reaction score
193
I will start first, so feel free!

6 years old boy visits hospital with his Mom. He complains about his headache and seems to walk strangely. Upon MSK exam, you noticed the boy is having upper extremity muscle weakness. When you use a cotton wisp to assess the patient's sensation, there is no abnormal sensation. What is the most likely diagnosis?

Members don't see this ad.
 
Tumor compressing part of the internal capsule plus CN 5? I'm having trouble seeing one thing causing two separate, distant lesions. Any more symptoms or signs?
 
Tumor compressing part of the internal capsule plus CN 5? I'm having trouble seeing one thing causing two separate, distant lesions. Any more symptoms or signs?
tumor is not a bad guess, but focus on the vignette's neuro exam. so this kid has hand muscle weakness with intact fine touch sensation.
 
Members don't see this ad :)
I will start first, so feel free!

6 years old boy visits hospital with his Mom. He complains about his headache and seems to walk strangely. Upon MSK exam, you noticed the boy is having upper extremity muscle weakness. When you use a cotton wisp to assess the patient's sensation, there is no abnormal sensation. What is the most likely diagnosis?

syringomyelia?
Edit: Woops, accidentally read it as "abnormal sensation" instead of "NO abnormal sensation"
 
Last edited:
I will start first, so feel free!

6 years old boy visits hospital with his Mom. He complains about his headache and seems to walk strangely. Upon MSK exam, you noticed the boy is having upper extremity muscle weakness. When you use a cotton wisp to assess the patient's sensation, there is no abnormal sensation. What is the most likely diagnosis?

Sooooooo...

Do we get to find out what that poor kid has?
 
  • Like
Reactions: 1 user
30 yr old stressed med student comes in with CC of flushing, dry face, tiny pupil, and drooped eyelid on his Lt. side. He also says he feels no pain and can't sense temp on his Rt side below his shoulder. What is the diagnosis? What would you do next?
 
30 yr old stressed med student comes in with CC of flushing, dry face, tiny pupil, and drooped eyelid on his Lt. side. He also says he feels no pain and can't sense temp on his Rt side below his shoulder. What is the diagnosis? What would you do next?

Sounds very familiar to the symptoms associated with cluster headache.. but no mention of any headache so I'm not sure that's what this is. Treatment would be sumatriptan if so.
 
  • Like
Reactions: 1 user
Members don't see this ad :)
30 yr old stressed med student comes in with CC of flushing, dry face, tiny pupil, and drooped eyelid on his Lt. side. He also says he feels no pain and can't sense temp on his Rt side below his shoulder. What is the diagnosis? What would you do next?

I would say Brown-Sequard lesion above T1 but not all the symptoms are there so I'm going to continue my trend and go with an expanding/late-stage syringomyelia above T1. MRI to look for cavity
 
It does sound similar to the cape-like distribution, so that makes sense. Yeah, probably syringomyelia.
 
Cape-like distribution with syringomyelia is bilateral.

Ipisilateral Horner synd. + contralateral loss of pain/temp = lat. medullary synd. from PICA or Vertebral a. infarct
 
Cape-like distribution with syringomyelia is bilateral.

Ipisilateral Horner synd. + contralateral loss of pain/temp = lat. medullary synd. from PICA or Vertebral a. infarct

With PICA you always get dysphagia and hoarseness and that is pathognomonic, but just because that wasn't mentioned doesn't mean you're not right. Definitely a possibility. Seems strange for a 30 y/o med student to have a stroke as well, but hey, it could happen.

I still think syringomyelia is most likely, as 20's-30''s is a typical age for it to present, but as you say, it is usually described as b/lcapelike loss temp/pain rather than u/l
 
Last edited:
  • Like
Reactions: 1 user
Sounds very familiar to the symptoms associated with cluster headache.. but no mention of any headache so I'm not sure that's what this is. Treatment would be sumatriptan if so.
I like your diagnosis of cluster headache associated with ptosis and myosis (Horner syndrome). But let's say he doesn't have headache and it's just Horner syndrome with contralateral tract signs below the lesion. What do you think?
 
Cape-like distribution with syringomyelia is bilateral.

Ipisilateral Horner synd. + contralateral loss of pain/temp = lat. medullary synd. from PICA or Vertebral a. infarct
Excellent man. Good job. So can anyone point out where the lesion is in terms of 1st, 2nd, and 3rd neuron? It would be the 1st neuron, which is considered to be sort of an emergency situation since stroke can cause this. I forgot which drug you can use to confirm that this is a 1st neuron lesion that causes Horner. Was it Cocaine or something like that?
 
A 3 yr old boy comes in to hospital with CC of vertigo and nystagmus. Further physical examination reveals motor ataxia. A molecular work up confirms a mutation in the gene that is involved in patterning along anterior-posterior axis. Diagnosis?
 
With PICA you always get dysphagia and hoarseness and that is pathognomonic, but just because that wasn't mentioned doesn't mean you're not right. Definitely a possibility. Seems strange for a 30 y/o med student to have a stroke as well, but hey, it could happen.

I still think syringomyelia is most likely, as 20's-30''s is a typical age for it to present, but as you say, it is usually described as b/l rather than capelike loss temp/pain.

I agree, nucleus ambiguous signs are pathognomonic, but just going off of what was there, lat. med. was the best fit with spontaneous dissection as the most likely cause in this age group. Can't really explain the Horner synd. with syringomyelia, right?
 
  • Like
Reactions: 1 user
I agree, nucleus ambiguous signs are pathognomonic, but just going off of what was there, lat. med. was the best fit with spontaneous dissection as the most likely cause in this age group. Can't really explain the Horner synd. with syringomyelia, right?

Spinal cord lesions above T1 could potentially cause Horner's, so the differential does include Syringomyelia, but also Brown-Sequard, Pancoast Tumor, Neck trauma, Demyelinating dz (MS), tumors of basal skull/pituitary, and also AICA/PICA infarction.

They were studying for boards and got a DVT that broke off and bypassed the lungs via patent foramen ovale.

Good call bro, almost forgot about the pesky patent foramen ovale ;)
 
Spinal cord lesions above T1 could potentially cause Horner's, so the differential does include Syringomyelia, but also Brown-Sequard, Pancoast Tumor, Neck trauma, Demyelinating dz (MS), tumors of basal skull/pituitary, and also AICA/PICA infarction.

Ah, I gotcha now. I was thinking more of the traditional syringomyelia sticking to the immediate pericentral canal area. I wasn't thinking about them expanding, but I see that's possible now and it's even in FA, good call.
 
  • Like
Reactions: 1 users
OK, I've got one..

A mother brings her 6 yo child into the emergency department because she has had abdominal pain and recently started vomiting. The child has an otherwise healthy PMH. They are currently living in the projects and have very little money to spend on housing, let alone healthcare. The mother has noted that her daughter has been walking with an unsteady gait as well, but thinks it could just be from her nausea. While in the ER she begins convulsing and the attending physician orders that they administer an antiseizure med.

Based on your clinical suspicion, what diagnostic test would help determine the cause of this young patients condition? What would the treatment options be?
 
  • Like
Reactions: 1 user
OK, I've got one..

A mother brings her 6 yo child into the emergency department because she has had abdominal pain and recently started vomiting. The child has an otherwise healthy PMH. They are currently living in the projects and have very little money to spend on housing, let alone healthcare. The mother has noted that her daughter has been walking with an unsteady gait as well, but thinks it could just be from her nausea. While in the ER she begins convulsing and the attending physician orders that they administer an antiseizure med.

Based on your clinical suspicion, what diagnostic test would help determine the cause of this young patients condition? What would the treatment options be?

Lead poisoning. Treatment is D-penicillamine, succimer, mercaperol, and EDTA.
 
is the above
OK, I've got one..

A mother brings her 6 yo child into the emergency department because she has had abdominal pain and recently started vomiting. The child has an otherwise healthy PMH. They are currently living in the projects and have very little money to spend on housing, let alone healthcare. The mother has noted that her daughter has been walking with an unsteady gait as well, but thinks it could just be from her nausea. While in the ER she begins convulsing and the attending physician orders that they administer an antiseizure med.

Based on your clinical suspicion, what diagnostic test would help determine the cause of this young patients condition? What would the treatment options be?
lead poisoning?
 
A 50 yr old female with CC of sudden dizziness and ringing in her Lt. ear. What test would you do to confirm the diagnosis?
 
yup FA15 page 490 says positional testing leads to delayed horizontal nystagmus, though I have no clue what that means lol! Has anyone seen an q form q banks?
 
yup FA15 page 490 says positional testing leads to delayed horizontal nystagmus, though I have no clue what that means lol! Has anyone seen an q form q banks?
Look on youtube. Some short close-up videos of testing.
 
  • Like
Reactions: 1 user


The first half of the video is immediate nystagmus seen in central vertigo, while the delayed type of nystagmus is the second half of video and represents a peripheral cause of vertigo. Pulled the info from firecracker
 
  • Like
Reactions: 1 user
Another question:

Patient presents to the neurologist with hemiparesis of the right side of his body. He also states that he has trouble seeing things on the left side of him. Moving in for a fundoscopic examination you notice the patient has a dilated right pupil that points to the right and towards the floor.

Diagnosis? Explain the specific cause of the hemiparesis on the right as well.
 


The first half of the video is immediate nystagmus seen in central vertigo, while the delayed type of nystagmus is the second half of video and represents a peripheral cause of vertigo. Pulled the info from firecracker


The last dude straight up snortin' ketamine lol
 
  • Like
Reactions: 1 user
Another question:

Patient presents to the neurologist with hemiparesis of the right side of his body. He also states that he has trouble seeing things on the left side of him. Moving in for a fundoscopic examination you notice the patient has a dilated right pupil that points to the right and towards the floor.

Diagnosis? Explain the specific cause of the hemiparesis on the right as well.
anyone have idea about diagnosis of this case ??
 
anyone have idea about diagnosis of this case ??
I will give it a shot. So weakness in the Rt. side of the body could indicate Lt. cortex injury. The guy is having trouble seeing through his Lt eyes. The pt's Rt eye is down and out indicating CN3 lesion. So there is a contralateral deficit and ipsilateral CN lesion signs, I will say it's gotta be one of the brain-stem lesion, though I can't think of any specific one. Am I heading to a right direction?
 
Another question:

Patient presents to the neurologist with hemiparesis of the right side of his body. He also states that he has trouble seeing things on the left side of him. Moving in for a fundoscopic examination you notice the patient has a dilated right pupil that points to the right and towards the floor.

Diagnosis? Explain the specific cause of the hemiparesis on the right as well.

CN3 Palsy= Lesion possibly due to PCA aneurysm (from HTN) or infartion from compression (of Uncal Herniation/Tumor)
Contralateral Hemiparesis= Lateral Striate artery lesion infarcting internal capsule or striatum or Cortical infarction.

CN3 Palsy (Ipsi) + Contralateral hemiparesis = ??? lol

I'm missing something here.

I know that:
CN3 Palsy (Ipsi) + Ipsilateral hemiparesis = Uncal Herniation.

Now you got me curious, what is it?
 
Another question:

Patient presents to the neurologist with hemiparesis of the right side of his body. He also states that he has trouble seeing things on the left side of him. Moving in for a fundoscopic examination you notice the patient has a dilated right pupil that points to the right and towards the floor.

Diagnosis? Explain the specific cause of the hemiparesis on the right as well.
Is it a tumor in the right occipital cortex leading to herniation and Kernohan's paralysis?
 
  • Like
Reactions: 1 users
so you are saying false localization sign?
Yes.
A tumor in the right occipital lobe gives the left hemianopia.
Herniation pushes the contralateral cerebral peduncle into Kernohan notch causing ipsalateral paralysis and ipsilateral CN III deficit.
One of the only things I can think of that involves hemiparesis and a CN III deficit on the same side.
 
  • Like
Reactions: 1 user
Yes.
A tumor in the right occipital lobe gives the left hemianopia.
Herniation pushes the contralateral cerebral peduncle into Kernohan notch causing ipsalateral paralysis and ipsilateral CN III deficit.
One of the only things I can think of that involves hemiparesis and a CN III deficit on the same side.

Isn't that exactly what I said? Uncal Herniation.
 
You didn't explain what led to the uncal herniation.

CN3 Palsy= Lesion possibly due to PCA aneurysm (from HTN) or infartion from compression (of Uncal Herniation/Tumor)
Contralateral Hemiparesis= Lateral Striate artery lesion infarcting internal capsule or striatum or Cortical infarction.

CN3 Palsy (Ipsi) + Contralateral hemiparesis = ??? lol

I'm missing something here.

I know that:
CN3 Palsy (Ipsi) + Ipsilateral hemiparesis = Uncal Herniation.

Now you got me curious, what is it?

I think I did mention the word Tumor right next to Uncal herniation.
 
  • Like
Reactions: 1 user
A mother brings in her 5 y/o son because she noticed that he started growing pubic hair and enlarged genitals. On examination the boy has signs of precocious puberty and you notice he has to move his head up in order to visualize your hands while testing the upper visual field. What is the underlying cause? How is the lesion affecting his vision? Why precocious puberty?
 
Top