Cerebral Vasoconstrictive Syndrome Case Study

Her drug screen showed positive benzodiazepines and blood alcohol was negative. Troponins were negative. Also, her initial work up showed acute kidney injury with a creatinine of 1.84, and potassium of 5.8. Her chest x-ray showed small amount of infiltrate in the right lower lobe. The CT scan of the head did not show any acute changes. The abdominal CT scan showed constipation and 6 mm opacity in her bladder. She had an electroencephalogram (EEG) which revealed diffuse generalized nonspecific encephalopathy. In addition, there was slowing of the left hemisphere consistent with left intracerebral lesion. The assessment diagnoses were acute respiratory failure (ABG of 87.287, pCO2 of 45.2, pO2 of 380 and biacarbonate of 20 on vent settings), altered mental status, attempted suicide, infectious process, medication use, hyperglycemic nonketotic, and less likely cerebrovascular accident given that her CT scan of the head was normal. She was admitted to the Intensive Care Unit under the care of Dr. Modupe Kehinde. She was intubated for airway protection and remained intubated until 5/23/2016 (7 days). She was on ventilator and was given nutritional support

Physical Examination: General: The patient is an alert, oriented male appearing his stated age. He appears to be in moderate distress. Vital signs: blood pressure 132/78 and pulse 68 and regular. Temperature is 38.56 oC (101.4 oF). HEENT:Normocephalic, atraumatic. Pupils were equal, round, and reactive to light. Ears are clear. Throat is normal. Neck: The neck is supple with no carotid bruits. Lungs: The lungs are clear to auscultation and percussion. Heart: Regular rate and rhythm. Abdomen:Bowel sounds are normal. There is rebound tenderness with maximal discomfort on palpation in the right lower quadrant. Extremities: No clubbing, cyanosis, or edema.

Extraocular muscles are intact. Conjunctivae are without erythema. No drainage or discharge from the eyes. There is no involvement of the eyelid and the nearest lesion is approximately 1.5 to 2 cm lateral to the left eye. He does have multiple vesicular lesions, some of which he has rubbed and no longer have the vesicle and appear to be just almost shallow ulcerations. This extends along the temporal area, on the left side into the ear canal itself and I do see similar lesions in the ear. Again, many of which have been ruptured and there is dried blood all through the canal as well. There is no other abnormality noted. There is no wax. I can see the TM. It does not appear to be involved. There is no involvement behind the ear. No pain at the mastoid process. Mucous membranes are moist. There is no mucosal lesions. No

A 62-year-old white male presented to the hospital for a scheduled ventriculoperitoneal shunt removal. The patient had developed cysts in the brain seventeen years ago in 1998 leading to increased intracranial pressures from accumulation of cerebrospinal fluid. After discovering the brain cysts, the patient underwent a ventriculoperitoneal shunt placement. Two years after the shunt was placed, the patient underwent another procedure for shunt revisions due to complications with infection. Now, the patient is presenting for removal of the shunt. In the pre-op holding area, the patient’s vital signs were taken. The patient’s blood pressure was 153/75, heart rate 80, respirations 18, oxygen saturation 93% on room air, and temperature was 36.5 degrees Celsius. Prior to the patient’s surgery, lab work was performed consisting of a CBC and CMP. The patient’s white blood cell count was 11.7, platelets 379, hemoglobin was 10.8 and hematocrit was 33. The patient’s potassium level was 3.7, calcium 9.1, sodium 145, BUN 35, and creatinine 2.21.

Also, a cardiac ECHO with Definity study was scheduled for 5/22/17 to reevaluate the LV thrombus, pending which a decision for anticoagulation was to be made. Inpatient Neurology evaluated him on 5/20/17, and also mentioned in their consult note that the patient had an acute CVA in April 2017, and recommended continuation of ASA and Plavix, along with considering initiating statins, and that MRI brain can be done after 6 weeks of stent placement if there were no contraindications (Although per the Neurologist’s note – the patient informed that he had PTCA 1 month ago, while in reality, his stent was placed in 3/2017; and a MRI of the brain was never subsequently done during this admission).

He also had right more than left mastoid opacifications and states that he was recently treated for otitis media. He has hypertension, hyperlipidemia, coronary disease and had been noncompliant with his medications in the past. His exam was essentially normal except for the subjective vertigo. There was no nystagmus and no diplopia on the initial exam. On 06/19/2015, he gave a different history. He states that he had a strike to the left temporal on Tuesday 06/16/2015. This did not result in any vertigo or any other neurological symptoms at that time. It was two days later that he had the vertigo at work. The patient also claimed that he had been seeing double since the previous night and the morning of the 19th. However, his neurological exam at that time, failed to reveal any actual disconjugate gaze. The patient had an MRI MRA, which revealed old white matter ischemic disease and mild intracranial atherosclerosis, but no evidence for acute stroke or posterior circulation significant stenosis. His diagnosis was labyrinthitis, possibly due to his bilateral mastoiditis. He was treated with Augmentin for 10 days. His symptoms resolved prior to discharge on meclizine. On physical therapy on discharge, he had no

During this quarter Jose did not experience any serious injuries. He experienced a hospitalization with admitting diagnosis of Acute Seizure (prolonged postictal lethargy and AMS) form 1/20/18 to 1/23/18; during his hospital staying, he consulted with the neurologist whom ordered an EEG that showed abnormal electroencephalogram consistent with independent interictal activity in both hemispheres supporting the diagnosis of chronic epilepsy; Trileptal was discontinued, no changes Keppra, Lamictal or Topamax. Other studies/workup included a CT head w/o contrast that showed chronic ethmoid sinusitis, normal chest x-ray, elevated ammonia levels, and low potassium (corrected). Prior his hospitalization Jose consulted with neurology on 11/21/17 who recommended the initiation of Trileptal, CT head if not done within 2017, and indicated that he may need a VNS if not improvement on refractory seizures. His next neurology follow up will be on 2/21/18.

Patient is a 19-year-old right-handed white female who is a fair historian. She states that she started having headaches as a child. Her father told her that he also had headaches and that they would eventually go away. She describes having a severe headache, which she calls her first migraine, after softball practice at age 12. Menarche was at age 13 with no change in her headaches. Her headaches have not been menstrually related. There was no clear change in her headaches during pregnancy or in the postpartum period. She states that she gets a dull headache two to three days out of a week. This is in variable locations on her head, but can also be a nuchal. The pain is of variable quality, but it does worsen with exertion. She also gets more

I did receive a significant amount of records from this patient's PCP, as well as neurology consult in followup and infectious disease notes. In short, he is a 67-year-old right-handed white male who while living in Alaska developed some hip pain, as well as medial right hand numbness. He did have an EMG on 10/2000 that showed ulnar neuropathy with cubital tunnel syndrome on the right. Ulnar nerve transposition was considered, but the patient deferred this. He did have an MRI of the cervical spine, which revealed most significantly C3-4, moderate bilateral neuroforaminal narrowing, C4-5 severe left and moderate right neuroforaminal narrowing, C5-6 severe bilateral neuroforaminal narrowing. He did

Patient is an 86-year-old right-handed white female who is a poor historian. She states she saw me several years ago, but cannot recall for what. She did see Geoffrey Starr, MD in 2011 for episodes of numbness and tingling in the right side of her cheek. He did a workup, which included the EEG, EMG, and carotid studies. She was complaining of some right upper extremity and left lower extremity numbness and tingling as well. These were all negative. Her PCP switched her from aspirin 81 mg to Plavix 75 mg. Dr. Starr added Trental to that. The patient states that over the years, she continued to have the numbness and tingling episodes of the right side of her face. The last several seconds at times, rarely

Cardiovascular Assessment: No visible pulsations, no heaves or lifts. Apical pulse present in the fifth intercostal space at the left midclavicular line. Auscultation of apical rate 62 beats per minute, normal rhythm regular S1 - S2 heart sounds present. Pulsations present when supine and disappear at a 45 degree angle position. Extremities are brown color without redness, cyanosis, lesions or varicosities bilaterally. Temperature warm bilaterally, Allen test was negative. Homan’s sign negative. Carotids: +2 and present bilaterally. Right Radial +2, left radial +1 , Right Brachial: +2

All cranial nerves tested within normal limits. Pt passed visual fields exam and no problems with gag reflex. Pt moved muscles evenly and bilaterally and was able to shrug shoulders and move head from side to side.

Generally, before fully losing consciousness, presyncopal symptoms include feeling faint, dizzy, lightheaded, hearing ringing, darkened or faded vision, and decreased hearing ability. The victim is overpowered by unsteadiness and weakness before blacking out. Inevitably, symptoms of the episodes continue until the vertigo (dizziness) overwhelms the victim, literally sending them into a whirl. One can know when to worry if symptoms like chest pain, dyspnea (difficulty breathing), low back pain, heart palpitations, severe headache, ataxia (loss of body movement control), or slurred speech occur. After the victim wakes up from fully losing consciousness, he or she feels a sensation of warmth, nausea, lightheadedness, temporary visual changes,

This is an 87-year-old female who presents to the emergency room complaining of a headache and weakness. Her medical history is known that she had long-standing history of migraine and is been followed in the outpatient setting by the neurology service. She is described as having chronic daily headache due to hemicrania continuan I believe it is a transformed migraine and feels she is also having some rebound headache from Fioricet dependence or there is a possibility of temporal arteritis. The recommendation on this admission is to check ESR CRP for possible temporal arteritis. It is also to be noted that she has an anemia and therefore she is seen in consult by GI and she also requires a PT/OT eval for an unsteady gait at baseline. Her

In a subarachnoid hemorrhage, bleeding occurs within the space between the brain and the skull. This type of stroke accounts for about 7% of all strokes. A subarachnoid hemorrhage is often signaled by a sudden thunderclap headache thats more severe than any you have ever felt. About half of all people who experience a subarachnoid hemorrhage die. Half of those who survive are left