NURS 480L Spinal Case Study latest (SPRING –FALL
SESSION) GRADED A+
On his first day of work at a hospital, a 28-year old SLP met a neurologist who
informally began discussing an interesting 20-year old patient she had just seen. The
patient had no apparent cognitive or communicative problem but presented with a
history of big appetite, excessive perspiration, irregular sleep-wake cycle, and altered
sexual behavior, with no libido. The neurologist noted that this was a classical case of
a lesion in the lower diencephalon. Hoe can you explain these symptoms in relation
to the lesion site? - ANSWER: It is a hypothalamic syndrome. The hypothalamus
serves autonomic, visceral and endocrine functions. These include sexual drive,
appetite, sleep-wake cycles, and body heat regulation.
An SLP read a report of a patient with impaired speech, language, cognitive and
sensorimotor functions subsequent to a TBI. The neurologic report identified
multiple sites with laceration and contusing tissues- most important, those involving
Brodmann areas 4, 3, 1, 2, 10, 11, and 38. What sensorimotor and behavioral
symptoms are you likely to see in this patient? - ANSWER: The Pt is likely to exhibit
impaired motor control (Brodmann area 4), altered somatic sensation (Brodmann
areas 3, 1, 2), cognitive disorders and personality changes (Brodmann ares 10 and
11), and aggressing and agitation (Brodmann area 38). This is due to the effects on
the amygdala and surrounding regions.
A 52-year old man was taken to a neurologist because for over 2 months he had
been exhibiting progressively greater amounts of confusion about time. He had also
been experiencing difficulty organizing his thoughts and making decisions. Lately, he
had began speaking somewhat incoherently with fewer grammatical markers and
words. The attending neurologist noted:
- time related confusion
- mild right-side hemiparesis
- right hemianopsia
- increased deep tendon reflexes and Babinski sign
- atlered personality
- expressive aphasia
- good auditory comprehension
The physician suspected a brain tumor. MRI results revealed a left cortical neoplastic
mass bordering the frontoparietotemporal region. The Pt was referred for a biopsy
then radiation treatment. How can these clinical signs be related to the structures
involved? What made the neurologist rule out a stroke during the examination? -
ANSWER: The involvement of the frontoparietotemporal tissue accounts for all of
the reported symptoms:
- time-related confusion is characteristic of parietal involvement
- expressive aphasia reflects involvement of anterior language area and altered
personality results from involvement of prefrontal projections
,- right-sided paralysis and positive Babinski sign indicate involvement of the motor
and surrounding cortex.
The progressive nature of the deficit rules out a CVA
The family of a 75-year old man with progressive difficulty with language and bladder
control took him to the family physician. Suspecting a case of a tumor, he ordered an
MRI investigation and SLP consult. MRI studies revealed 2 tumors: first involving the
temporal parietal regions in the left hemisphere and second involving the cauda
equina region of the spinal cord. Pt had difficulty in urinary retention and fecal
continence. SLP eval noted markedly confused and incoherent language with
moderate memory problems. How can these social symptoms be related to lower
spinal tumor? - ANSWER: The tumor in the cauda equina region affected sacral
motor control. The spinal nerves from the sacral region innervate the bladder and
anal sphincters.
A temporal-parietal tumor affecting the language and cognitive cortex accounted for
his cognitive and linguistic deficits.
A 30yo man who had a history of being social, detail oriented and focused had
gradually changed, becoming depressed, indifferent, and socially detached. For the
past 2-3 months, he did not want to work and spent time sitting, staring, and
procrastinating. He was seen by a neurologist who noted the following:
- indifferent attitude and little desire to do anything
- easily distractible
- socially inappropriate use of language
- impaired sense of smell
-paucity of verbalization
A brain MRI revealed a tumor in the anterior cranial fossa bilaterally affecting the
frontal lobes. How can these symptoms be related to the associated region of the
brain? - ANSWER: The bilaterally located tumor had affected the inferior cortex. The
inferior cortex deals with personality and regulates executive-cognitive functions,
such as reasoning, abstract thinking, self monitoring, and planning.
The reported behavior deficits (altered personality, profanity, inactivity and
inappropriate behavior) implicate the orbitofrontal region.
The tumor had also compressed the olfactory bulb and its tract, which accounts for
the loss of sensation of smell.
A 60-year old woman developed severe dysarthria after undergoing carotid
endarterectomy. This is a surgical procedure used to clean the artherosclerotic
plaque from the right internal carotid artery, a major artery that supplies blood to
the brain. The surgeon assured the Pt that the symptoms would resolve soon and
she could expect full recovery. The consulting SLP noted the Pt exhibiting:
- paresis involving the right half of the face
- paralysis of the right half of the tongue
- unintelligible slurred speech
- slow articulatory movements
,- aphonia, diplophonia, breathiness
- difficulty swallowing
- good comprehension and no signs of aphasia
What CN were affected in the Pt? - ANSWER: The observed symptoms indicate that 3
CN were affected:
- CN VII: related to paresis of right side of face and contributed to dysarthria
- CN XII: involved with the paralysis of the tongue and contributed to dysarthria
- CN V: contributed to VF paralysis and aphonia, diplophonia and breathiness
- All 3 CN: contributed to articulatory precision causing speech to be unintelligible
A 60-year old man presented with the complaint that he was easily tired and needed
rest even after a mild exertion. The neurologist noted the following:
- 6-month history of doplopia
- respiratory weakness with shallow breathing and limited vital capacity
- progressive weakness including slurred speech after a brief period of physical
activity
- near-normal strength after rest
- no cognitive or linguistic deficit except speech intelligibility after exertion
- the administration of edrophonium (Tensilon), and inhibitory drug, resulted in
improved physical strength of the Pt. This led the neurologist to suspect a myoneural
problem.
What is the suspected diagnosis based on the motor weakness and speech
intelligibility after sustained physical activity? - ANSWER: In myasthenia gravis, the
problem lies at the myonueral junction; the motor end plate is damaged by the
antibodies, whish work against achetylcholine receptors. This leads to restriction of
muscle contraction and causes muscles to easily fatigue. Because normal-appearing
muscles fatigue with persistent motor tasks, the stress testing is used to confirm this
condition. The muscle fatigue haas a generalized effect on all motor speech
processes.
A 45-year old man fell while taking a shower and was found by his wife lying on the
floor, fully conscious. Realizing that something was not right, she advised him to take
a rest. Within a few hours, his speech became unintelligible and he told his wife
about the pain and weakness he experienced in his right arm. At this point, the wife
drove him to the ER, where the physician noted:
- paresis in the right arm
- severe pain in right shoulder and arm
- sensation of paresthesia (burning and pricking) in the right arm
- lowered pain threshold
- speech unintelligibility because of dysphonia and imprecise articulation
- some emotional instability marked by frequent bursts of crying or panic
- some word-finding deficit
- excellent comprehension for written and spoken language
, The presence of sensorimotor impairments without any sign of aphasia led the
physician to suspect a subcortical lesion. The brain MRI study reveale - ANSWER: A
CVA in the Pt affected the posterior region of the left thalamus and part of the
internal capsule carrying descending motor fibers; this results in the following:
- weakness in the arm and speech muscles subsequent to the interruption of
adjacent motor fibers in the internal capsule
- severe pain sensation caused by the overreaction of the primitive pain mechanism
of the thalamus secondary to the lesion
- emotional instability, usually seen after a thalamic lesion
- anomia subsequent to the involvement of the thalamocortical (parietal lobe)
projections, which is a common constituent of the thalamic syndrome
A 55-year old female truck driver began experiencing difficulty seeing while driving
particularly on the left side. She made and appt with a neurologist who noted the
following:
- lest homonymous hemianopia, manifested as loss of vision in contralateral left
fields of both eyes
- definitive difficulty in understanding spoken language
- noticeable confusion in identifying the direction of sound sources
- increased confusion in focusing on the physician when there were noises outside
the room and when an announcement came on the intercom system
- normal pure tone threshold on audiometric testing
- normal vision acuity
- no sign of speech, language, or cognitive disorder
The brain MRI study revealed a small infarct involving the lateral posterior inferior
area of the right thalamus. What thalamic nuclei are in this region of the thalamus?
How can these nuclei be related to the selective visual and auditory symptoms? -
ANSWER: This area is the site of part of the geniculate and pulvinar bodies. The
involvement of the geniculate bodies (LGB and MGB) appear to be implicated int eh
case. The involvement of the LGB resulted in the loss of the left visual fields for both
eyes, also called left hemianopsia. The involvement of the adjacent MGB contributed
to central auditory processing deficits, marked by a normal hearing threshold but
impaired processing and reduced ability to identify the direction of the sound.
A 55-year old man presented with slurred and slowly articulated speech with the
sensation of numbness but no pain in his mouth. There was no other symptom
present. There was no limb weakness, aphasia, or any sign of reduced cognitive
functioning. The brain MRI Study revealed a small infarct in the caudal region of the
ventral posterior nucleus in the left thalamus.
Of the following thalamic nuclei that mediate somatosensation from the face, which
is likely to be involved?
- ventral lateral
- ventral anterior
- ventral posterior lateral
- ventral posterior medial
SESSION) GRADED A+
On his first day of work at a hospital, a 28-year old SLP met a neurologist who
informally began discussing an interesting 20-year old patient she had just seen. The
patient had no apparent cognitive or communicative problem but presented with a
history of big appetite, excessive perspiration, irregular sleep-wake cycle, and altered
sexual behavior, with no libido. The neurologist noted that this was a classical case of
a lesion in the lower diencephalon. Hoe can you explain these symptoms in relation
to the lesion site? - ANSWER: It is a hypothalamic syndrome. The hypothalamus
serves autonomic, visceral and endocrine functions. These include sexual drive,
appetite, sleep-wake cycles, and body heat regulation.
An SLP read a report of a patient with impaired speech, language, cognitive and
sensorimotor functions subsequent to a TBI. The neurologic report identified
multiple sites with laceration and contusing tissues- most important, those involving
Brodmann areas 4, 3, 1, 2, 10, 11, and 38. What sensorimotor and behavioral
symptoms are you likely to see in this patient? - ANSWER: The Pt is likely to exhibit
impaired motor control (Brodmann area 4), altered somatic sensation (Brodmann
areas 3, 1, 2), cognitive disorders and personality changes (Brodmann ares 10 and
11), and aggressing and agitation (Brodmann area 38). This is due to the effects on
the amygdala and surrounding regions.
A 52-year old man was taken to a neurologist because for over 2 months he had
been exhibiting progressively greater amounts of confusion about time. He had also
been experiencing difficulty organizing his thoughts and making decisions. Lately, he
had began speaking somewhat incoherently with fewer grammatical markers and
words. The attending neurologist noted:
- time related confusion
- mild right-side hemiparesis
- right hemianopsia
- increased deep tendon reflexes and Babinski sign
- atlered personality
- expressive aphasia
- good auditory comprehension
The physician suspected a brain tumor. MRI results revealed a left cortical neoplastic
mass bordering the frontoparietotemporal region. The Pt was referred for a biopsy
then radiation treatment. How can these clinical signs be related to the structures
involved? What made the neurologist rule out a stroke during the examination? -
ANSWER: The involvement of the frontoparietotemporal tissue accounts for all of
the reported symptoms:
- time-related confusion is characteristic of parietal involvement
- expressive aphasia reflects involvement of anterior language area and altered
personality results from involvement of prefrontal projections
,- right-sided paralysis and positive Babinski sign indicate involvement of the motor
and surrounding cortex.
The progressive nature of the deficit rules out a CVA
The family of a 75-year old man with progressive difficulty with language and bladder
control took him to the family physician. Suspecting a case of a tumor, he ordered an
MRI investigation and SLP consult. MRI studies revealed 2 tumors: first involving the
temporal parietal regions in the left hemisphere and second involving the cauda
equina region of the spinal cord. Pt had difficulty in urinary retention and fecal
continence. SLP eval noted markedly confused and incoherent language with
moderate memory problems. How can these social symptoms be related to lower
spinal tumor? - ANSWER: The tumor in the cauda equina region affected sacral
motor control. The spinal nerves from the sacral region innervate the bladder and
anal sphincters.
A temporal-parietal tumor affecting the language and cognitive cortex accounted for
his cognitive and linguistic deficits.
A 30yo man who had a history of being social, detail oriented and focused had
gradually changed, becoming depressed, indifferent, and socially detached. For the
past 2-3 months, he did not want to work and spent time sitting, staring, and
procrastinating. He was seen by a neurologist who noted the following:
- indifferent attitude and little desire to do anything
- easily distractible
- socially inappropriate use of language
- impaired sense of smell
-paucity of verbalization
A brain MRI revealed a tumor in the anterior cranial fossa bilaterally affecting the
frontal lobes. How can these symptoms be related to the associated region of the
brain? - ANSWER: The bilaterally located tumor had affected the inferior cortex. The
inferior cortex deals with personality and regulates executive-cognitive functions,
such as reasoning, abstract thinking, self monitoring, and planning.
The reported behavior deficits (altered personality, profanity, inactivity and
inappropriate behavior) implicate the orbitofrontal region.
The tumor had also compressed the olfactory bulb and its tract, which accounts for
the loss of sensation of smell.
A 60-year old woman developed severe dysarthria after undergoing carotid
endarterectomy. This is a surgical procedure used to clean the artherosclerotic
plaque from the right internal carotid artery, a major artery that supplies blood to
the brain. The surgeon assured the Pt that the symptoms would resolve soon and
she could expect full recovery. The consulting SLP noted the Pt exhibiting:
- paresis involving the right half of the face
- paralysis of the right half of the tongue
- unintelligible slurred speech
- slow articulatory movements
,- aphonia, diplophonia, breathiness
- difficulty swallowing
- good comprehension and no signs of aphasia
What CN were affected in the Pt? - ANSWER: The observed symptoms indicate that 3
CN were affected:
- CN VII: related to paresis of right side of face and contributed to dysarthria
- CN XII: involved with the paralysis of the tongue and contributed to dysarthria
- CN V: contributed to VF paralysis and aphonia, diplophonia and breathiness
- All 3 CN: contributed to articulatory precision causing speech to be unintelligible
A 60-year old man presented with the complaint that he was easily tired and needed
rest even after a mild exertion. The neurologist noted the following:
- 6-month history of doplopia
- respiratory weakness with shallow breathing and limited vital capacity
- progressive weakness including slurred speech after a brief period of physical
activity
- near-normal strength after rest
- no cognitive or linguistic deficit except speech intelligibility after exertion
- the administration of edrophonium (Tensilon), and inhibitory drug, resulted in
improved physical strength of the Pt. This led the neurologist to suspect a myoneural
problem.
What is the suspected diagnosis based on the motor weakness and speech
intelligibility after sustained physical activity? - ANSWER: In myasthenia gravis, the
problem lies at the myonueral junction; the motor end plate is damaged by the
antibodies, whish work against achetylcholine receptors. This leads to restriction of
muscle contraction and causes muscles to easily fatigue. Because normal-appearing
muscles fatigue with persistent motor tasks, the stress testing is used to confirm this
condition. The muscle fatigue haas a generalized effect on all motor speech
processes.
A 45-year old man fell while taking a shower and was found by his wife lying on the
floor, fully conscious. Realizing that something was not right, she advised him to take
a rest. Within a few hours, his speech became unintelligible and he told his wife
about the pain and weakness he experienced in his right arm. At this point, the wife
drove him to the ER, where the physician noted:
- paresis in the right arm
- severe pain in right shoulder and arm
- sensation of paresthesia (burning and pricking) in the right arm
- lowered pain threshold
- speech unintelligibility because of dysphonia and imprecise articulation
- some emotional instability marked by frequent bursts of crying or panic
- some word-finding deficit
- excellent comprehension for written and spoken language
, The presence of sensorimotor impairments without any sign of aphasia led the
physician to suspect a subcortical lesion. The brain MRI study reveale - ANSWER: A
CVA in the Pt affected the posterior region of the left thalamus and part of the
internal capsule carrying descending motor fibers; this results in the following:
- weakness in the arm and speech muscles subsequent to the interruption of
adjacent motor fibers in the internal capsule
- severe pain sensation caused by the overreaction of the primitive pain mechanism
of the thalamus secondary to the lesion
- emotional instability, usually seen after a thalamic lesion
- anomia subsequent to the involvement of the thalamocortical (parietal lobe)
projections, which is a common constituent of the thalamic syndrome
A 55-year old female truck driver began experiencing difficulty seeing while driving
particularly on the left side. She made and appt with a neurologist who noted the
following:
- lest homonymous hemianopia, manifested as loss of vision in contralateral left
fields of both eyes
- definitive difficulty in understanding spoken language
- noticeable confusion in identifying the direction of sound sources
- increased confusion in focusing on the physician when there were noises outside
the room and when an announcement came on the intercom system
- normal pure tone threshold on audiometric testing
- normal vision acuity
- no sign of speech, language, or cognitive disorder
The brain MRI study revealed a small infarct involving the lateral posterior inferior
area of the right thalamus. What thalamic nuclei are in this region of the thalamus?
How can these nuclei be related to the selective visual and auditory symptoms? -
ANSWER: This area is the site of part of the geniculate and pulvinar bodies. The
involvement of the geniculate bodies (LGB and MGB) appear to be implicated int eh
case. The involvement of the LGB resulted in the loss of the left visual fields for both
eyes, also called left hemianopsia. The involvement of the adjacent MGB contributed
to central auditory processing deficits, marked by a normal hearing threshold but
impaired processing and reduced ability to identify the direction of the sound.
A 55-year old man presented with slurred and slowly articulated speech with the
sensation of numbness but no pain in his mouth. There was no other symptom
present. There was no limb weakness, aphasia, or any sign of reduced cognitive
functioning. The brain MRI Study revealed a small infarct in the caudal region of the
ventral posterior nucleus in the left thalamus.
Of the following thalamic nuclei that mediate somatosensation from the face, which
is likely to be involved?
- ventral lateral
- ventral anterior
- ventral posterior lateral
- ventral posterior medial
