There are 486 questions on various topics in Neurology in the FrontalCortex neurology question bank.

Comprehensive Neurological Workup

Topic: Adult

Created on Thursday, August 23 2007 by dryman

Last modified on Thursday, August 23 2007.

A 28-year old right-handed man with no prior medical history visits the opthalmologist for followup after refractive surgery for unilateral astigmatism the previous month. A normal left fundus is visualized, but an incidental finding is made of a small foul-smelling suppurative abscess in his right anterior hard palate. He is immediately sent to oral surgery and the abscess is drained; cultures are pending but results of a PCR-based assay are specific for P. aeruginosa. LP is obtained with normal opening pressure and clear appearance, but CSF cultures and chemistry are not yet back from the lab. A transesophageal echochardiogram is negative.

The nursing staff notes that the patient suddenly exhibits a significant degree of dysphagia during lunch. On afternoon rounds, the patient's speech is slurred and he has developed a lower right facial droop with significant right facial numbness. He recent onset of nausea, photophobia, tinnitus, nuchal rigidity, and a moderately severe holocranial headache that is worse when standing. His left pupil is dilated and hyporeactive, while his right pupil is reactive and normal. The remainder of the neurological exam is unremarkable; a CT is obtained and is negative for hemorrhage. J D Miles MD PhD orders you to administer a massive bolus of IV TPA, stat. Quickly, as you are drawing up the injection, what is the most likely diagnosis?


 
        A) Iatrogenic factitious disorder
 
        B) Unruptured berry aneurysm of the posterior communicating artery
 
        C) Multiple cardioembolic brain infarctions
 
        D) Meningitis secondary to transmission from bacterial abscess
 
        E) Internal carotid artery infarction
 

 


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This question was created on August 23, 2007 by dryman.
This question was last modified on August 23, 2007.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ANSWERS AND EXPLANATIONS




A) Iatrogenic factitious disorder

This answer is correct.


The patient's presentation is not fully consistent with any of the other listed diagnoses. In this young patient with no prior medical history, side effects of procedures are the most probable cause of his symptoms.

The acute onset of nausea, photophobia, tinnitis, nuchal rigidity, and headache worse when standing is consistent with a post-LP spinal headache. Likewise, dysphagia can be a result of transesophageal echocardiography. During oral surgery, the patient received novocaine injections affecting the right periorbital muscles and the maxillary branch of CN V, causing hemifacial numbness and a mechanical dysarthria and lower facial droop. The opthalmology junior dilated only his left eye for the followup exam, eventually resulting in a bizarre malpractice suit when the patient was put on inappropriate TPA and billed for an extensive stroke workup.

  (See References)

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B) Unruptured berry aneurysm of the posterior communicating artery

This answer is incorrect.


An aneurysm of the posterior communicating artery could compress CN III and cause anisochoria, but it is unlikely to explain his other neurological symptoms.  (See References)

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C) Multiple cardioembolic brain infarctions

This answer is incorrect.


Patients with a bacterial abscess could be at risk for multiple strokes from showering of emboli secondary to bacterial endocarditis, but in this case a transesophageal echocardiogram did not demonstrate any source of cardiac embolism.  (See References)

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D) Meningitis secondary to transmission from bacterial abscess

This answer is incorrect.


Concern about potential infection from an oral abscess is appropriate; however, in this patient with a recent clear normal pressure LP and no prior symptoms, the acute onset of nausea, photophobia, tinnitus, nuchal rigidity, and headache worse when standing are more likely related to another etiology. His focal neurological symptoms are not typical of meningitis.  (See References)

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E) Internal carotid artery infarction

This answer is incorrect.


In carotid stenosis, ischemia can be a cause of contralateral facial motor and sensory deficits and also of ipsilateral episodic vision loss (amaurosis fugax), but it is not associated with ipsilateral anisochoria.  (See References)

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References:

1. Rowland, L.P. (Ed) (2000). Merritt's Neurology, 10th Edition. Lippincott Williams & Wilkins, Philadelphia.
2. (2000). "Risk of dysphagia after transesophageal echocardiography during cardiac operations." , 69(2) 486-9; discussion 489-90. (PMID:10735685)
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adult
Comprehensive Neurological Workup
Question ID: 082307165
Question written by dryman. (C) FrontalCortex.com 2006-2009, all rights reserved. Created: 08/23/2007
Modified: 08/23/2007
Estimated Permutations: 600

User Comments About This Question:

1 user entries
 

jdmiles
adult Nice Aug 24, 2007 @ 02:30

Nice one, dryman.

Don't think I didn't notice how you stuck me in there.

-jdm 



 
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