NURS 2534: Processes of Human Diseases 1

Unit 2 (Nervous System Disorders)

Case Study 1

A 50-year-old left-hand-dominant man presents to his primary care physician with complaints of
right-hand weakness. He says 6 months ago he began dropping things with his right hand. In the
subsequent months, his grip strength has weakened further and his handwriting has deteriorated.
He has also noticed frequent twitching in the muscles of his right hand, forearm, and shoulder,
and he has developed painful muscle cramps in his neck and back. He also reports occasional
problems swallowing his food and says his speech seems “thicker.” The patient reports no other
significant past medical history and denies any lower extremity disturbances or sensory deficits.
Vital signs are within normal limits. The patient’s cranial nerve examination is significant for
atrophy of the tongue, which also demonstrates fasciculations upon protrusion. On motor exam,
the patient has significant thenar atrophy of the right hand, but not on the left. Right hand
strength is 3/5, and left hand strength is 4/5. Triceps and biceps are 4+/5 bilaterally and deltoids
are 5/5 bilaterally. Neuromuscular examination of the lower extremities is normal. Reflexes are
3+ in the upper extremities bilaterally and he also has a brisk jaw jerk reflex. Sensory
examination is normal. The patient’s gait is normal, and he exhibits no ataxia.
1. The likely diagnosis is amyotrophic lateral sclerosis.
2. The etiology of ALS is a progressive degenerative disease with motor neurons in the
upper and lower extremities are affected. It is characterized by wasting/atrophy of the
hands, arms and legs. Dementia can also be a factor in ALS. Patients diagnosed with ALS
are likely to have poor prognosis ultimately leading to paralysis than death within a few
years.
3. The clinical manifestations of ALS include:
 Dysarthria, dysphagia, tongue atrophy and fasciculations
 Typically no sensory, cognitive or oculomotor deficits
 Combined UMN (upper motor neurons) and LMN (lower motor neurons) lesion
signs
Case Study 2

An 80-year-old woman is brought to her nurse practitioner by her daughter for a medication
check. During the visit, the patient has trouble answering questions about events that took place
in the past month, and at one point stops to ask her daughter where she is. Her daughter
comments that she has recently been disoriented in familiar environments, that she has trouble
coming up with the names of people and objects, and that she recently forgot to turn off the stove
at home, setting off the fire alarm. Vital signs are as follow: Temperature = 36.5°C; HR =
90/min; BP = 130/80 mm Hg. Neurologic examination reveals no focal deficits, but she scores a
22/30 on the Mini-Mental State Examination, losing points because she is not oriented to the date
or day of the week, is unable to recall words that she has been asked to remember after a brief
delay, and is unable to copy a simple figure.
1. The likely diagnosis is primary degenerative dementia – Alzheimer's
 2. The etiology is varied depending on the exact classification but this disorder is often
preceded by “alcoholism, intracranial tumor, normal-pressure hydrocephalus” among
others (Marsh, 2019, p. 918)
3. Typical manifestations consist of anterograde amnesia; aphagia; apraxia; agnosia, and
other cognitive disturbances. Along with these the patient may also present with deficits
in language, abstract though, and other forms of higher executive function.

Case Study 3

An 18-year-old woman is brought to the ED by EMS after a motor vehicle accident (MVA). The
patient was alert when the paramedics arrived at the scene, but her level of consciousness
declined en route to the hospital. The patient told the paramedics that she was not wearing a
seatbelt and that she hit the windshield during the collision. On presentation the patient is drowsy
but responsive to verbal commands. She complains of back and neck pain and a headache. There
is a contusion and abrasion over her right temporal region; the remainder of her head, ear, eye,
nose, and throat examination is normal. Neurological examination reveals no focal deficits, and
that cranial nerves II–XII are intact. Vital signs, a CBC, and blood chemistry test results are
within normal limits. A lateral x-ray of the cervical spine reveals no abnormalities. Non-contrast
CT scan of the head shows a small skull fracture in the temporal region and an underlying extra-
axial lenticular hyperdensity.

Questions

1. What is the most likely diagnosis?

a. Hematoma, subdural or epidural?
2. What is the etiology of this condition?
a. A bleed between the dura and bone (epidural) OR between the dura and arachnoid
membranes (subdural), due to the MVA and temporal skull fracture.
3. What are the clinical manifestations of this condition?
a. LOC fluctuates, herniation and death may occur, chronic subdural hematomas can
cause dementia.
-symptoms of a subdural hematoma typically have a slower onset than those of epidural
hematomas because the bleed is slower, so that could be why her symptoms are relatively mild
right now?