Case study anatomy 232 (1)

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Portland Community College *

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232

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Anatomy

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Jan 9, 2024

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pdf

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Case study anatomy 232 C ASE S TUDY #1 - CNS B RAIN VS . S PINAL C ORD Dr. Green and Dr. Carter were nearing the end of the first year of their medical residency in the emergency department of County General Hospital. It had been a long year and a long week. They had been on duty for the last 12 hours and things were not slowing down. "What are your plans for the weekend, Ken? " Dr. Green asked. "Sleep, what else? " Dr. Carter replied. "I hope things slow down a bit," Dr. Green said to himself. Suddenly, a call came over the radio. Paramedics were bringing in a young man with injuries sustained in a diving accident. A minute later, the doors to the department burst open and the paramedics wheeled in a young man. "What gives?" Dr. Green asked. The senior paramedic, Jim Morrison, reported that the patient was swimming at the local quarry and did a forward flip into the water, striking some submerged rocks. "Which part of his body struck the rocks?" asked Dr. Carter. "He was in a hyperflexed-tucked-position when he hit the rocks, lacerating the right side of his head and neck and upper back. The patient indicated he had severe pain upon impact and loss of sensation and movement in his arm and leg. He may have lost consciousness, but he's not sure. He also complains of a severe headache, dizziness, and nausea. When we arrived at the scene we immobilized, stabilized and transported him immediately," Jim explained. Looking at the patient, Jim continued. "His name is Mike Smith, and he's 22 years of age. His vital signs include slightly lowered blood pressure (100/70), heart rate of 75 beats per minute, respiration normal, and he is conscious and alert." As the patient was being prepped for examination, Dr. Carter and Dr. Green discussed how they should approach their evaluation. Dr. Carter started by saying, "After seeing the head wound and the amount of blood loss, and hearing his complaints, I want to confirm my suspicion that this patient has a brain injury." Dr. Green disagreed: "I think that the other signs and symptoms indicate a spinal cord injury, and that's what we should investigate." The following table summarizes the findings of the evaluation, which included a physical exam, X-rays, magnetic resonance imaging (MRI), and neurological tests. Table 1 Summary of Diagnostic Testing for Mike Smith Sensory Testing • Decreased sensation to touch, pressure, and vibration in the right upper/lower extremities • Decreased temperature discrimination (cold vs. warm) in the left upper/lower extremities Motor Testing • Decreased strength and movement of the right upper/lower extremities during muscle testing • Decreased strength and movement of left abdominal muscles • Absence of triceps and biceps reflexes in the right upper extremity • Abnormal response of patellar, Achilles (hyper) reflexes in the right lower extremity • Positive Babinski sign on the right foot • Abnormal cremasteric reflex in the right groin region General Examination • Abnormal pupil response of right eye (constriction)

• Other vital signs within normal limits • Cognitive testing normal (counts backward from 100 by 7s; knows name, date, place) X-Ray and MRI Examination • No fractures present in the skull • Fracture in the 7th cervical vertebra • Significant swelling present in the spinal canal in the C7-T2 region • Spinal cord appears to be intact Discussion Questions 1. Based upon the findings presented, which doctor made the correct initial prediction? I believe that Dr. Green made the correct initial prediction because of the loss of sensation in his limbs. The test showed there is a fracture to his vertebrae and there are no fractures present or signs of damage to the skull which houses the brain. But there is significant swelling to the C7-T2 region making me side with Dr. Green's assessment that it was the correct one. 2. Based upon previous knowledge of brain function, what results from the testing were consistent with a brain injury? Results from the testing that is consistent with brain injury are the abnormal pupil constriction with the right eye. The positive Babinski test shows that there is an abnormal reaction which is a sign of an upper motor neuron injury, and, all other symptoms suggest spinal cord injury 3. Based upon previous knowledge of spinal cord function, what results from the testing were consistent with a spinal cord injury? Based on previous knowledge of the function of the spinal cord, the results from the motor and sensory exam were consistent with that of a spinal cord injury. such as the decreased sensation to touch, pressure, and vibration in the right upper/lower extremities and decreased strength and movement of the right upper/lower extremities during muscle testing. This would explain the numbness and inability to feel his arm and leg. Likewise, the significant swelling present in the spinal canal in the C7-T2 region which connects the neck with the upper back indicates a form of inflammatory response in that area. This is consistent with the patient's severe neck pain and ache and could suggest some form of spinal injury in that area. 4. Based upon previous knowledge of CNS function, what results could be consistent with both types of injury? Spinal cord injury • Abnormal response of patellar, Achilles (hyper) reflexes in the right lower extremity • Absence of triceps and biceps reflexes in the right upper extremity

• Decreased strength and movement of left abdominal muscles • Decreased strength and movement of the right upper/lower extremities during muscle testing • Fracture in the 7th cervical vertebra -Brain injury • Decreased sensation to touch, pressure, and vibration in the right upper/lower extremities • Decreased temperature discrimination (cold vs. warm) in the left upper/lower extremities • Abnormal pupil response of right eye (constriction) • Cognitive testing normal (counts backward from 100 by 7s; knows name, date, place) 5. Assuming the incorrect diagnosis is true, predict how the findings would be different. If it was a brain injury instead as Dr. Carter suggested, the findings would show the patient exhibiting problems with their sense of smell and taste. This could be due to damage to the olfactory nerves that is responsible for transporting the smell sensation from the nose to the brain, as well as, damage to the processing of smell located in the olfactory center of the brain. C ASE STUDY #2 – T HE E NDOCRINE S YSTEM # 2 A H ISTORY A 50-year-old man presents with enlargement of the left anterior neck. He has noted increased appetite over past month with no weight gain, and more frequent bowel movements over the same period. Physical Exam He is 5'8" tall and weighs 150 lb. The heart rate is 82 and the blood pressure is 110/76. There is an ocular stare with a slight lid lag. The thyroid gland is asymmetric to palpation, weighing an estimated 40g (normal = 15-20g). There is a 3 x 2.5 cm firm nodule in the left lobe of the thyroid. Questions 1.What do you think the patient's primary problem is? The patient's primary problem is likely thyroid-related, specifically thyroid gland enlargement or goiter, as indicated by the asymmetric enlargement of the thyroid gland and the presence of a thyroid nodule.

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