Clincal Cases Final

8/2/2019 Clincal Cases Final

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Clinical CasesYear 4, Unit 8 , 2009


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Case 1

A 60 year old hypertensive patient has admitted to hospital with the

following clinical features :o Right eye showed ptosis and the eye ball was deviated

downwards and laterally , the left eye was normal

o Hemianesthesia , left side of his body.

o The left leg displayed spontanueus abnormal movements.

There were no other motor abnormalities in the limbs.

Q1: State the expected finding on examination of this patient right pupil.

Inspection dilated pupil (Mydrasis)

Reflex absence direct reflex in the right eyeIndirect reflex is normal in the left eye

Q2: Explain the anatomical basis for each clinical features seen in this patient

Right ptosis oculomotor nerve innervate the levator palperea superiosis ifthere is palsy.

Deviation of right eye downward and laterally antagonist action of the lateralrectus(abducens) + superior oblique muscle (trochlear)

Hemianasthesia in left - injury to the medial laminscus + spinothalamic tract.

Abnormal movement injury to the red nucleus

Q3: Name the artery that is likely to have been damaged in this .?Posterior communicating + posterior cerebral


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Case 2

Draw the lateral diagram of left cerebral cortex showing primary +association areas

1- Name the gyri

See a picture from the book

2- Name the blood supply

Anterior cerebral artery medial ( motor + sensory)

Middle cerebral artery lateral

Posterior cerebral artery occipital

3- Clical effects of damage to these areas

Frontal eye field eye goes to lesion side

Primary motor paralysis

Broca's +wernik's aphasia

Prefrontal no higher mental functions ( planning, judgment , etc)

Primary sensory anesthesia

2ndry sensory asteriognosis

Primary occipital homonymous heminopia , macular intact

2ndry visual no recognition

Primary auditory bilateral loss of hearing (more in the opposite side)

2ndry auditory word deafness


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Case 3Patient presenting with Parkinson-like symptoms (Quadrad of Bradykinesia, resting

tremor, rigidity, and postural instability). The patient fails to show any signs of

cerebellar dysfunction (ataxia, nystagmus, hypotonia, pendular reflexes, etc.)

Q1) Anatomical basis of Parkinsons: Considered to be a disease of the Basal ganglia-

direct motor pathway(function is the initiation of voluntary movements)-Projections from the dopaminergic neurons of the Substantia nigra pars compacta drive the

direct motor pathway, and degeneration of these neurons causes reduced function of the

direct motor pathway (hence the start hesitation, short steps, etc.)2) Blood supply to the basal ganglia and surrounding subcortical structures (This is

important for strokes since the internal capsule is the most common site for a lesion that

produces complete contralateral hemi-anaesthesia or hemiparesis (Note the wordhemiparesis does NOT equate with hemiplegia- the later usually implies involvement of the

rubrospinal tracts as well, which descend from the Red nuclei at the level of the brainstem.

Q3) The patient has parkinsons syndromeQ4) How may other motor system disorders present?

UMNs-spasticity, hyper-reflexia and hypertonia- Abnormal reflexes re-emerge Babinski

LMNs and Cerebellar signs (read em up) Note that only cerebellar and LMN producehypotonia, also know lesions of the indirect motor pathway of the Basal ganglia produce

Chorea athetosis dystonia tics, hemiballismus (subthalamic nucleus) etc.

Deep branches of the Anteriorand Middle cerebral arteries MCA-(the middle striate and

lenticulostriate arteries.

respectively).

Anterior choroidal artery, may

be a branch of the MCA, or adirect branch of the Internal

Carotid)

Deep branches of the Posteriorcerebral artery; the

thalamoperforating and

thalamogeniculate aa.)Thalamus

Putamen and Globus

Pallidus

Anterior limb of

nternal capsule

Posterior limb of

internal capsule

Genu


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Case 4

Draw a diagram of cross section of the spinal cord showing the location ofthe descending tracts

Medial longitudinal fasiculus , ventral corticospinal , tecto-pontine spinalreticulospinal , lateral vestibulospinal , medullary reticulospinal, rubrospinal,lateral corico-spinal.

It is known that immediately following a stroke there could be bladderenlargement with retention of urine. Following recovery , there could stillbe evidence of urinary incontinence of some kind explain thisanatomically?

Normal:Sympathetic lumbar 1,2 >>> Hypogastric plexuses

Parasympathetic sacral 2,3,4>>> pelvic splenchec nerve

During shock:Attonic bladder:Bladder muscle relaxSphincter contractedDistended bladderNo voluntary control

During recoverey:1- Automatic reflex bladder ( above sacral segment)

a. Descending fibers are damaged no voluntary control*

2- Autonomous bladder (below sacral ganglion

a. no reflex control or no voluntary control.

b. the bladder wall is flaccid

c. the bladder fill then overflows

*See neuroanatomy , snell page 413


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Case 5

Examination of a patient who had undergone mastoidectomy ,

revealed the following

o Loss of wrinkles over the left side of forehead

o Loss of naso-labial fold on the left side.

o Depression of the left angle of the mouth

o Loss of taste sensation over anterior 2/3 of the

left side of the tongue

Q1: Name the nerves which had been damaged in this patient.

Facial nerve

Q2: What is the relationship between the nerve injury an the

mastidectomy?

From the net : The facial nerve starts in the brain, and then tracks through a

narrow space located inside the ear (internal auditory canal). The nerve thenpasses through the middle ear (behind the ear drum) and leaves through another

narrow passage located under the ear area (stylomastoid foramen)

Q3: With a diagram, state the course of nerve which has been injured and

name the branch

Check moore , cranial nerves chapter, figure 9.7 page 1144 (really good in

shr7 this)

Q4: Innervations of the tongue

Facial taste of the anterior 2/3 of the tongue

Glosspharyngeal taste and sensation of the posterior 1/3


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Trigeminal ( V3) lingual nerve sensation of the anterior 2/3 of thetongue

Hypoglossal motor


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Case 6

Symptoms : 6 year old child presented with severe pain in the left earandOn examination: nasal and pharyngeal congestion.

Diagnosis after investigations - acute otitis mediaIn this patient describe the expected appearance of left tympanicmembrane on otoscopy?Bluging , redness (erythema) , edema

State the innervations of the tympanic membrane?

External auriculotemporal of V3 , aurical branch of vagus (x)

Internal CNIX ,

Explain anatomically the relationship between the inflamed pharynx and

otitis media?Inflamed pharynx is connected with the middle ear by eustchian tubeIt's shorter , more horizontal in childrenName 2 sites in the head from which pain could be refereed to the ear andstate the anatomical basis for this ?Temporomandibular joint + pharynx ( CN8)


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Case 7

Following surgery on the right side of the neck a patient developes

the following

1- Right-side dryness of facial skin

2- Smaller right palpebral fissure than the left.

3- Smaller right pupil as compared to the left one

1- Name the structures that has been damaged in this patient

Sympethatic nerve brain stemsuperior cervical ganglion

2- Damage at which other sites could produce similar effects?

Hypothalamus spinal cord as nerve emerges1st thoracic nerve root* brainstem

*At the 1st thoracic nerve there is either complete ptosis or partial ptosis

because sympethatic

3- explain the anatomical basis for findings in the right eye using a

diagram


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Case 8

Severe pain , redness in right eye

Increased intraocular pressure

Shallow anterior chamber The left eye was normal

1- Name the condition?

Closed angle glocoma

2- Formation pathway, distribution of aques hymerus?

Aques humorus formation by cilliary process posterior chamber

anterior chamber trabecular meshwork canal of shlem sclera

vein.

3- Anatomical bases of this condition?

Aques humor is not drained coz the angle is closed (iris is protruded

anteriory) increased intraocular pressure.

4- Princible of management

1- Decrease formation B blockers / carbonic anhydrase inhibitors

2- Increased drainage parasympathetomemtics

3- Surgery open the angle


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Case 9

A teenager squeezed on inflamed postule ( boil) on the left side of hisupper lip. Few days later he developed high fever, drowsiness andopthalmoplegia. After thorough clinical examination and immediateinvestigation he was diagnosed as having thrombosis of the left cavernoussinus.

1- State the venous pathway(s) taken by microorganism to reach the

cavernous sinus in this patient?

Facial veindeep facial vein ptyrigoid plexus cavernous sinus

Facial vein inferior and superior ophthalmic veins cavernous sinus

2- Name the veins and venous sinuses to which the cavernous sinusis directly connected (draw a diagram)

Moore , figure 7.12(b) , page 913

1-Inferior petrosal sinus

2-Superior pertosal sinus

3-Sphenoparital sinus

4- intercavernous sinus

5- Superior ophthalmic vein

3- A) name the nerves that are directly likely to be affected in this

patient?

Oculomotor , trochlear , abducents , ophthalmic part of the trigeminal

Moore, figure 7.12(c) , page 913

b) state the clinical features that would be seen in a patient after damage

to each one of these nerves

3,4,6 no eye movement , no pupilary reaction , ptosis


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V1 loss of sensation in the area supplied by this nerve


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Case 10

Child patient presenting with meningitis , they performed kerning's andbrodinski's , and he has neck stiffness.

Q1: what is the nerve supply of the dura?

1) supratentorial duraophthalmic branch of trigeminal nerve CNV1

2) dura in anterior, middle & posterior fossaa. Anterior fossa: ophthalmic branch of trigeminal nerve CNV1b. Middle fossa: maxillary & mandibular branches of trigeminal nervec. Posterior fossa: vagus, C1, C2, C3

Q2: explain on anatomical basis why the patient had neck stiffness?

Since the neck is supplied by C1,C2,C3 which supply the dura ,These nerves gets irriateted from the meningitis , so the patient doesn't move hisneck from the pain carried by those nerves.

Q3: describe kerning's and brodnski's signs ,state the anatomical basis of thesesigns?

Kerning's flex the hip with the knee flexed then extend the knee, by this uirritate the meningies by stretching of the sciatic nerve , in order to relieve thepain , the patient flexes his neck ( kerning's positive).

Brodnski's flex the neck of the patient , the meningies gets irritated so thepatient flexes his knee to relieve this pain ( brodnski's postitive)

Q4: where to perform lumbar puncture in a child?L4-L5

Q5: name the layers through which the needle passes during the lumbarpuncture?Skin subcoutanous tissue supraspinous ligament intaspinous ligament epidural space dura subdural space arachinoid - subarachinoid

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Clincal Cases Final