NERVOUS SYSTEM MODULE

NERVOUS SYSTEM

CASE 1

CASE 1: ROLLING BACK

ID: AT, 1 3/12 y/o, male and of Malilipot, Albay

● Informant: Lola Susan (Percentile Reliability – 80%)
CC: Seizure and fever
HPI:
● 12 hrs PTC, AT’s temperature 37.9C for which he was given 5 ml of Paracetamol
120mg/5mL and the fever came down to normal. He was eating well and was playful.
He had colds and was given Loratadine.
● 9 hrs PTC, AT suddenly had a seizure described as symmetric stiffening of her upper
and lower extremities. He fell down on the floor, eyes were described as “rolling back”,
bluish discoloration around the mouth, and unresponsiveness while jerking for about 5
minutes. The informant who was with AT said that his head did not hit the floorand was
holding him during the seizure. About 3 minutes after the seizure, AT was seen playing
with his toy gun. This time his fever was 39.3C. He was given a sponge bath. The
informant was hesitant to bring the AT to the hospital because of COVID fear. She was
trying to contact the parents who are in abroad for advice.
● 30 minutes PTC, again AT had another episode of seizure that lasted for 3 minutes
which prompted consult at nearest hospital.

ROS
● General – no weight loss
● HEENT – colds
● CV – no difficulty of breathing
● Pulmonary – no cough, no increased work of breathing
● GI – no diarrhea

Past History:
● Prenatal. Perinatal and Neonatal History
● Mother had regular prenatal checkup
● AT was born premature through CS due to maternal hypertension
● BW – 2.8 kg, placed in an incubator for 1 week.
● Thriving well after discharge in the hospital.

Past Medical History

● No history of hospitalization
● Occasional cough and colds, given medication by her pediatrician
 ● No history of seizure

Immunization: Received in the health center accompanied by the lola.

Family History
● Only child in the family
● Father and Mother – HTN, both controlled with Amlodipine
● No diabetes
● Mother (one episode of seizure while with fever around 2 yr old)

Social History:
● Both parents are working abroad and AT is left under the care of her maternal
grandparents.
● Mother, 30 yr old, nurse; Father, 32 yr old, care giver. Both are in Canada. The father
smokes.
● Grandfather – smokes and drinks alcohol.

Nutrition History
● Mixed feeding since birth.
● Sample diet: Breakfast – 1 cup of rice, egg, hotdog, 1 glass of milk
● Lunch: 1 cup of rice, burger ulam
● Snack: sandwich, juice
● Dinner: 1 cup of rice, fried chicken, 1 glass of milk

Development History: At par with her cousins her age.

PE
● General – Playful, alert, interactive and smiled responsively
● VS – CR – 85 RR – 22 Temp – 37.9C
● Weight – 14 kg Length – 94 cm
● Skin - no rash, no laceration, no hematoma
● Eyes – no redness, pupil bilaterally equal and reacting to light
● Nose – clear nasal discharge
● Ears – minimal cerumen both ears, no watery discharge, no redness, no pain
● Lungs – normal bilateral chest expansion, normal bilateral air entry, no rales, no
wheezes
● Cardiac – no murmur, normal S1 and S2
● Abdomen - normal bowel sounds, no tenderness, no masses palpated
● Extremities – equal pulses
● Neuro Exam – (-) Nuchal rigidity, Kernig (-) Brudzinski (-), (+) withdrawal and
localization to touch

Diagnostics: none
Medications: Paracetamol 120mg /5 ml – 7.5 ml q 4-hour PRN for fever
● Cefixime 100mg/5ml – 3.5 ml BID
● Sinupret for Kids – 5 ml TID
● Cetirizine syrup – 5 ml OD HS

Disposition: sent home with home instruction:

● Avoid excessive clothing
● Tepid sponge bath if still with fever after giving paracetamol
● Educated about the possible recurrence of fever.
● Follow up after 3 days

GUIDE QUESTIONS:
1. What are the pertinent data in the 1st handout?
2. What are your differentials for fever and seizure?
3. How do you evaluate a patient who presents with first fever with seizure?
4. What are the different types of seizure?
5. What is febrile seizure?
6. What are the risk factors for recurrence of febrile seizures and occurrence of epilepsy
after a febrile seizure?
7. What is bacterial meningitis?
8. Discuss the clinical manifestations of acute meningitis?
9. What is aseptic meningitis?
10. What are the pertinent data in the 2nd handout
11. How do you assess child’s level of consciousness?
12. What constitutes a positive Kernig’s and Brudzinski’s signs?
13. What are the vaccines preventable diseases that cause meningitis? WHat is the
childhood immunization schedule for these vaccines?
14. What are the pertinent data in the 3rd handout?
15. Will you request for CSF analysis for this patient with no signs of meningitis?
16. Is CT Scan necessary before performing a LP in this patient?
17. What are the contraindications for performing LP?
18. How do you perform LP?
19. How do CSF finding vary in bacterial and viral meningitis in children beyond neonatal
period?
20. Describe the morphologic changes seen in patients with bacterial meningitis
21. Discuss the pharmacologic treatment in bacterial meningitis?
22. Discuss the pharmacology of beta lactams, specifically Penicillin

CASE 2
CASE 2

ID: ED, 75 yo, female, a retired manager of a telecommunications, from Malilipot Albay
Chief Complaint: Memory and cognitive function loss
History of Present Illness:
● 2 years PTC, Patient was noticed by her daughter in law that she is becoming
repetitive with her words during their conversation. She started to have memory loss of
the names around her, and even executive function loss was noticed by other family
member.
● 1-year PTC, she started to forget to pay her house utilities which sometimes resulted
to disconnection of service. She also frequently misplaces or forget to take items
(keys, pursue).
○ She became withdrawn from socially or mentally challenging situations
(potentially due to being unable to keep up with information) with her family
members.
● 9 months PTC, she started experiencing frustration or irritability due to difficulties
leading to increase arguing because she is not seeing issues that are being pointed
out about them. She even suspected her housemaid of stealing items. She has
difficulty recalling phone number, and address.
● 6 months PTC, she got lost while walking around their village which made her
daughter in law worried. She became impulsive with odd decision making.
● 3 months PTC, she is started to forget family members or call them by wrong name.
Her speech became incomprehensible.
● 3 weeks PTC, she started to hallucinate and delusions of things around her that other
family members do not see.
● 1-week PTC, she requires assistance with bathing, grooming, dressing, and eating.
She has general urinary incontinence and started wearing adult diapers.
● 3 days PTC, she requires help in walking.

GUIDE QUESTIONS:
1. What are the pertinent data in the first handout?
2. What are Neurodegenerative diseases?
3. What is Dementia?
4. How does Dementia start?
5. What is the cause of Dementia?
6. What happens in the early stages of Dementia?
7. How does Dementia affect the brain?
8. What are the stages of Dementia?
9. What are the usual clinical features of Alzheimer’s disease (AD)?
10. Discuss the etiology and pathophysiology of AD
11. Discuss the molecular genetics involved in AD
12. Describe the pathological features seen in AD
13. Discuss the different types and stages of AD
 14. What is Parkinson’s disease (PD)?
15. What are the clinical manifestations of PD?
16. Discuss the epidemiology and pathogenesis of PD
17. Discuss the molecular genetics of PD
18. Describe the pathological features seen in PD
19. What is Parkinson’s disease dementia and Dementia with Lewy bodies?
20. Are there any diagnostics needed to diagnose AD and PD? If yes, discuss each
procedure
21. Discuss the pharmacologic treatment in AD
22. What are the non-pharmacologic treatments of PD
23. Discuss the pharmacologic treatment in PD

CASE 3

CASE 3
Identifying Data: FG, 59-year-old male, retired policeman, from Ligao Albay
Chief Complaint: Headaches and difficulty concentrating over the past 6 weeks.
History of Present Illness:
● 6 weeks PTC, patient complaint of headaches and difficulty concentrating. He
describes the headaches as occurring primarily over the right frontal temporal region
and describes it as “dull” in nature. He has experienced occasional nausea but no
vomiting with the headaches.
● 4 weeks PTC, he had difficulty focusing and concentrating on tasks at hand, such as
reading the newspaper or playing cards. His wife states that he has been more
irritable, moody, and “not himself”.
● 2 weeks PTC, he complained of severe dull right frontal headache accompanied with
nausea and vomiting. He self-medicate with Paracetamol 250 mg, Propyphenazone
150 mg, Caffeine 50 mg (Saridon Triple action) which rendered temporary relief to
him.
● 1 weeks PTC, the headaches persisted with intense dull characteristics frontal
headache. He again self-medicated with Celecoxib 200 mg tab PO for the pain and
Saridon triple action which gave temporary relief from his symptoms.
● 3 days PTC, He complains severe right frontal headache.
● Persistence of headache prompted consult at the OPD.

Past Medical History:

● He has been healthy all his life and presents yearly for an annual checkup. He has no
history of DM, hypertension, and bronchial asthma.
● He has no history of previous hospitalization and surgery.
● He has no food or drug allergy.
Personal and Social history: He has no history of alcohol abuse. However, he admits to a
30-pack-a-year smoking history.

Review of Systems: The review of systems is significant for weight loss and productive
cough.

Physical Examination:
● General survey: Patient is oriented to person, time, location, and situation. He
becomes upset during the examination.
● VS: BP= 120/80mmHg; CR= 80 bpm, RR= 18cpm, T= 36.8 C
● Neurologic examination:
○ Cranial nerve and sensory examination findings are unremarkable. Motor
strength testing is normal except for questionable weakness in the left finger
extensors. The deep tendon reflexes are normal except for a Babinski sign
present on the left. With ambulation, he has less arm swing on the left than the
right.

Patient was requested with Cranial CT scan w/ contrast.

Propyphenazone/Caffeine (Saridon) was increased to 3x a day.
Patient was advised admission if there will be worsening of headache.

GUIDE QUESTIONS:
1. What are the pertinent data in the 1st handout?
2. Define headache, give the difference between the primary headache and secondary
headache
3. What is the pertinent data in 2nd handout?
4. What other data do you need in a neurologic history?
5. What is your consideration at this point?
6. What is a babinski sign?
7. WHat are the different deep tendon reflexes?
8. What is the most likely diagnosis to the case?
9. WHat diagnostic procedures should you request?
10. Describe the different brain tumors and their clinical features? Discuss your differential
diagnosis
11. WHat is a metastatic brain tumor? What are the clinical presentations ad pathogenesis
of metastatic brain tumor?
12. What is the diagnostic approach to metastatic brain tumor?
13. What is midline shift in metastatic brain tumor?
14. What is brain herniation?
15. What is the role of oral corticosteroids in metastatic brain tumor?
16. What is the role of anticonvulsants?
17. What other pharmacologic and non-pharmacologic management for metastatic brain
tumor?