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more tough neurology case


more tough neurology case


حالة سريرية

الوصف الكامل Background

A 36-year old school teacher was evaluated for headaches and left arm weakness. The headaches began approximately 2 years previously, following an episode of severe coughing. Dull occipital pain had persisted on and off since that time. In addition, she had noted dull pain in the left hand during the past year. Six months ago she noted the onset of progressive numbness and weakness of the left hand and she reports that she is now unable to distinguish the temperature of bath water with her left hand. During the past month she also has found that her walking is "stiffer than usual." There have been no bowel or bladder abnormalities and her general health is otherwise well.
Examination was remarkable for mild thoracic kyphoscoliosis. Cranial nerve testing revealed a pupillary asymmetry (left, 1 mm, right 3 mm). Both pupils were round and reactive. There was, in addition, a left ptosis; the left side of her face appeared drier than on the right. There was marked atrophy of all muscle groups in the left arm. There was complete loss of pain and temperature perception from C5 to T1 on the left and patchy abnormalities of pain and temperature sensation in the right forearm. Position and vibration perception were normal throughout. She was areflexic in the left arm and hyperreflexic in the right arm and in both legs, with moderate spacticity of both legs. Gait was mildly stiff legged, but otherwise unremarkable

كتابة حرة وطرح موضوع النقاش!

What could be the cause for the unequal size of pupils and ptosis?

Why would one side of her face be drier?

Which area in the spinal cord could be involved to give the above symptoms?
What do you think the diagnosis is ?

Al Durra's picture
by
بعد التخرج

1&2
is it bcz of horner Syn in the left side.?

3) the cervical spine?

DAM's picture
DAM



سبب الاطراق وعدم تناظر الحدقتين هو اصابة العصب الودي الموجود ضمن العصب الثالث ويأتي هذا العصب الودي من العقد الودية في النخاع الرقبي ...أعتقد عند C2-c3-C4 والاصابة تؤدي الى متلازمة هورنر التي تتظاهر أيضاًَ بعدم تعرق نصف الوجه
..
واعتقد أن الصداع الموجود هو بسبب ديسك في الفقرة الرقبية الاولى والثانية والذي يؤدي الى ألم منعكس على شكل صداع في المنطقة القفوية وقد ينتشر للأمام

الاجابة على ما أعتقد :
الاصابة تتوضع من C1-T1 في القسم الايسر من النخاع
C1-C2 سبب الصداع
c4-T1 منشأ الضفيرة العضدية ..هناك اصابة محيطية (اصابة نورون سفلي ) أدت لضعف اليد
وجود الصمل يدل على اصابة نورون علوي ..وكون الصمل في الطرفين السفليين معاً فالاصابة لا تقتصر على القسم الايسر من النخاع بل امتدت لتشمل أقسام من الايمن

gardeania's picture
gardeania
بعد التخرج


still waiting Exclamation

Al Durra's picture
Al Durra
بعد التخرج


excellent guys!
right answers & logical explanations but still waiting for the diagnosis

to make it easyer , focus on the temp&pain sensation loss

NOW!!

what do u think ?
if you need an image , go to the radio lab in our faculty and seek out it >>>

Al Durra's picture
Al Durra
بعد التخرج

it is a tough one ....

well i will try ...

for the first quastion... its horner... no doubt..

for the second quastion ... in the cervical spine...

for the third quastion... i dont know but this distribution of loss in the pain and tempureture without position and vibration let me think in anterior spinal artery syndrome( from the mild thoracic kyphoscoliosis) .. especially with upper neuron problem in the lower extermitis which means corticospinal tract defect... but i am not sure about it.... so if it is wrong ... SAMHONA

SALAM

marabd's picture
marabd


well , i admit that it`s a tough case
i think it will be easier if you see this image on the following link
http://gait.aidi.udel.edu/educate/clcsimge/syrsco2.jpg

Al Durra's picture
Al Durra
بعد التخرج


sorry i didn't see the 3rd question
is it syrengomyelia

DAM's picture
DAM

Quote:
is it syrengomyelia

but there won't be hyperreflexia there will be hyporeflexai

Hot sauce's picture
Hot sauce
طبيب مقيم


Syringomyelia is kind of disease that is tough clinically but easy radiologically

For Hot sauce , i reffered to the Oxford handbook and i will write some clarifying points

as syrinex enlarge , they expand into adjacent grey & white matter , compressing decussating spinothalamic fibers anteriorly , the ventral horn , and the corticospinal fibers

cardinal signs : wasting & weakness of the hands and arms with loss of pain & temp sensation
other features : Horner`s synd and UMN signs in the legs

Al Durra's picture
Al Durra
بعد التخرج


oops...

inspite i didnt catch it ... thank you very much...

marabd's picture
marabd


thank u dr Al Durra for the case ..

gardeania's picture
gardeania
بعد التخرج
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