Interesting case

[beyond all hope]

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48 year old guy with history of migraines present with 45 minutes of sudden onset taste change "it tastes like metal in my mouth", paraesthesias of his left face, arm and leg, dizziness/vertigo, possible slurring of speech and blurry vision.

On exam he has a total vertical gaze palsy, can't raise or lower his eyes, pupils sluggishly reactive, otherwise normal motor-sensory exam, no pronator drift, but left sided dysmetria and leftward-falling ataxia.

Your differential?
Your workup?
The answer is?

(I'll tell you, I was in the right ballpark but my DDx didn't include the actual Dx)

 

[Wackie]

"it tastes like metal in my mouth",

He's pregnant. 😀


Appologies...I just wanted to participate in my own special way. 🙁

 

[kbrown]

48 year old guy with history of migraines present with 45 minutes of sudden onset taste change "it tastes like metal in my mouth", paraesthesias of his left face, arm and leg, dizziness/vertigo, possible slurring of speech and blurry vision.

On exam he has a total vertical gaze palsy, can't raise or lower his eyes, pupils sluggishly reactive, otherwise normal motor-sensory exam, no pronator drift, but left sided dysmetria and leftward-falling ataxia.

Your differential?
Your workup?
The answer is?

(I'll tell you, I was in the right ballpark but my DDx didn't include the actual Dx)

lateral medullary infarct, some type of weird seizure/post ictal state, thalamic infarct, with many different areas effected...some embolic process showering different areas, possibly supranuclear opthalmoplegia (though this is a chronic dx)

head ct r/o bleed (unlikely), mri with dwi, maybe an echo if showering considered, optho consult

lateral medullary infarct (wallenburg, sp???)

seriously don't have a clue, just a few of the presenting symptoms reminded me of things that I saw while on neuro, but nothing that I can really fit into one dx. oh....and i am a dumb intern, so disregard anything i say.

 

[whasupmd2]

agreed, that's what I was thinking as well, wallenberg sx.

 

[kalico]

DDX:
Neurologic migraine
CVA
Unwitnessed seizure
Brain mass
Recent trauma

Workup:
Vital Signs
Fingerstick glucose
CBC, SMA7
CT head (CT neck if neck pain or trauma)
Fundoscopic exam

 

[igcgnerd]

for any possible stroke patients we have a standing orders for blood glucose, cbc, ua, tox screen, abg, blood culture
When dealing with any hypoxic brain injury after giving the initial findings to the doc, mri and chest x ray are ordered incase tpa is indicated

to me it sound like some sort of hypoxic brain injury or if there were any recent trauma bossibly an epidural hemotoma?: full workup and mri

 

[kbrown]

for any possible stroke patients we have a standing orders for blood glucose, cbc, ua, tox screen, abg, blood culture
When dealing with any hypoxic brain injury after giving the initial findings to the doc, mri and chest x ray are ordered incase tpa is indicated

to me it sound like some sort of hypoxic brain injury or if there were any recent trauma bossibly an epidural hemotoma?: full workup and mri

okay, certainly...
glucose, abg, chem, utox, lytes, etc...but after that, what i said.

 

[StevenRF]

This is easy... he got hit in the head with a metal baseball bat.

 

[Hayduke]

I know it's probably out-of bounds but I have a few questions;
Any heralds, aura etc?
Is the dysguesia lateralized?
When was his last migraine and what was its character?
Is he having any pain?
Any travel?
What part of the country are we talkng about?
Race?
Is he immunocompromised, or does he look like an AIDS/CA player?
Drug use?
Occupational exposures?

DDX:
Neurologic migraine
CVA
Unwitnessed seizure
Brain mass
Recent trauma

I like these, but would like to flesh a couple of them out a bit:
CVA-medullary infarct/PICA territory embolism/vertebral artery dissection
Brain mass+paraneoplastic syndromes

And will add
Infection-Lyme(a stretch), CNS crypto, any bacterial/viral encephalitis, amebiasis, syphillis (limbering up from this stretching)
Toxin-heavy metal/poisoning (arsenic etc.)
Workup:
Vital Signs
Fingerstick glucose
CBC, SMA7
CT head (CT neck if neck pain or trauma)
Fundoscopic exam[/QUOTE]

Would do same save expand to CMP to check LFTs.

More info pleez.

 

[kbrown]

where is the OP with more 411???

 

[Hayduke]

BAH-
Hello???!!

 

[Hard24Get]

bump - I'm expecting some type of metal poisoning or characteristic seizure/tumor/stroke pattern