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4 - The Unsteady Bookeeper

1. AK, a 62-year-old bookkeeper, presented to the ER with dizziness, vertigo, and difficulty walking after waking from a nap. 2. Her neurological exam found decreased muscle tone on her right side, intention tremor, and broad-based gait indicating damage to her right cerebellum. 3. A CT scan revealed a hemorrhage on the right side of her brain likely caused by her long-standing hypertension.

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78 views

4 - The Unsteady Bookeeper

1. AK, a 62-year-old bookkeeper, presented to the ER with dizziness, vertigo, and difficulty walking after waking from a nap. 2. Her neurological exam found decreased muscle tone on her right side, intention tremor, and broad-based gait indicating damage to her right cerebellum. 3. A CT scan revealed a hemorrhage on the right side of her brain likely caused by her long-standing hypertension.

Uploaded by

kvguan7090
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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The Unsteady Bookeeper

Key Terms

Vertigo: The sensation of moving around in space or of having objects move around the person.

Hypertension: A condition in which the patient has a higher than normal blood pressure.

Intention tremor: A tremor exhibited or intensified when attempting coordinated movements.

Supple neck: No pain or discomfort on passive flexion and extension of the neck.

Lipohyalinosis: The neuropathologic changes noted in the small arteries that result in small
cerebral infarctions.

History and Exam

History of the present illness


AK is a 62 year-old woman who is brought to the emergency room by her friend because of
dizziness and difficulty walking.
AK took a nap the evening before admission, and when she awoke later that evening, she
experienced some nausea, dizziness, and vertigo. She arose and had difficulty walking to the bathroom,
holding onto the furniture and the walls. In the bathroom, she reportedly vomited once and then fell
asleep sitting on the commode. She slept there overnight and awoke the next morning complaining of a
bifrontal headache and continued to experience nausea and dizziness. She therefore called a friend, who
took her to the emergency room.

Past medical history


She has a history of hypertension for the past 15 years and exertional angina for the past 5 years.
She works as a bookkeeper for a local fuel oil company.

Medications
eta-blocker for hypertension. Nitroglycerine tablets as needed for chest pain.

Physical examination
She is moderately obese. BP = 200/130 mmHg; P = 76/min, regular. She presents with no
evidence of head trauma, and her neck is supple. There is a soft systolic murmur along the left ventricular
outflow tract, and there are no carotid bruits.

Neurological exam
She is sleepy but answers questions appropriately. Her fundi reveal flat optic discs with some
copper wiring. Her pupils are equal and symmetrically reactive to light. On extraocular muscle testing, she
has coarse nystagmus on right gaze. On motor testing, some decreased muscle tone in the right arm and
leg is noticeable, but her bulk and strength are normal. Intention tremor and dysmetria were found on
right finger-to-nose and heel-to-shin testing. Sensory testing is normal. Her reflexes are normoactive and
symmetrical. On standing to walk, with assistance, her gait is broad-based, and she tilts towards the right
side. She is unable to perform a tandem gait.
A head CT scan is emergently obtained (Figure 1).

Questions

1. Name the areas of the nervous system that, when damaged,


cause a decrease in muscle tone (hypotonia). Why is her muscle tone
decreased on the right side?

Her muscle tone is decreased on the right side because the right
cerebellum is affected, and the right cerebellum has control over
muscle tone.
-Possible damaged systems: Lower Motor Neurons, and cerebellum, as
well as the early symptoms of upper motor neuron lesions.

2. Do cerebellar lesions produce ipsilateral or contralateral


symptoms? Why?

Cerebellar lesions produce ipsilateral effects, because efferent tracts


from the cerebellum cross over twice before reaching the cerebellum.

3. Why did she develop vertigo, nausea, and dizziness?


Headache?
She developed vertigo, nausea, or dizziness possibly due to Cranial
Nerve 8 being affected, likely due to the mass on the left side. The
headache may be due to a hemorrhage.

4. Her CT is shown in Figure 2. A pathologic specimen from a


patient who died from a similar condition is shown in this figure. What
do you think is the etiology of her lesion?
The lesion appears to be a hemorrhage on the right side of her
brain. As stated in the patients history, she had high blood
pressure which could have led to the hemorrhage.
5. Hemorrhage into the brain is one type of stroke. Define
stroke, and list other causes of stroke.
A stroke is a lesion in the brain caused by a lesion in the blood
vessels of the brain. There can be an ischemic stroke, which
occurs when a clot occludes blood flow, and a hemorrhagic stroke,
where a blood vessel bleeds.

6. What role does hypertension have in her illness?


Hypertension most likely made her sensitive to a hemorrhagic stroke,
as increased pressure in the vessels puts more strain on the walls of
the vessels.

7. Why is CT superior to MRI in this clinical setting?


This is because CTs are much more sensitive to hemorrhage than
MRIs.

8. If the patient were to become lethargic, what do you think


might be going on?
As the brainstem has a large part to play in level of consciousness,
lethargy may be a sign of the lesion affecting the brainstem, perhaps
via increased pressure.

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