A*******s
发帖数: 9638 | 1 今天被一个医生朋友的电话揪到了医院， 他给他一个亲戚做了个手术， 今天是第2天。
67 yrs old female had a cervical laminectomy for her cervical myelopathy
yesterday. Her initial symptoms include gait disturbance. After the surgery
, she was found to have a right arm weakness and right pupil dilatation. She
had been in respiratory failure after the surgery and currently she was on
biPAP.
ICU nurse was apparently panic after she saw the dilated right pupil which
was new and confirmed by her family members.
PMH: HTN， Glucoma.
Social/family： not contributory
She currently is not on any meds.
on exam, she was arousable but a little confused. She was able to talk. Her
right pupil was 6 mm and sluggish to the light, left is 1 mm. There is no
doubt of right arm weakness. All other PEs are not remarkable.
Her CT of head was normal.
I was very puzzled with the presentation, especially not sure if she has a
left Horner's with right sided weakness or right third nerve palsy with
right sided weakness.
What are you going to do next step? |
m*********6
发帖数: 609 | |
A*******s
发帖数: 9638 | 3 Why?
【在 m*********6 的大作中提到】
: brain MRI?
|
s******t
发帖数: 579 | 4 Check her eye movement and see possible CN III injury.
C and upper T spine – CT or MRI to r/o Horner’s syndrome induced by possible surgery injury or hematoma.
chest CT too - lung cancer (less likely since no smoking history.) |
A*******s
发帖数: 9638 | 5 1. She is not cooperative enough to follow up comments.
2. Good thought on surgical complications.
3. Too early to consider Pancoast.
possible surgery injury or hematoma.
【在 s******t 的大作中提到】
: Check her eye movement and see possible CN III injury.
: C and upper T spine – CT or MRI to r/o Horner’s syndrome induced by possible surgery injury or hematoma.
: chest CT too - lung cancer (less likely since no smoking history.)
|
s******t
发帖数: 579 | 6 MRA - to see aneurysm (hx of HTN) and any infarction (post-operational
stasis and embolization). |
A*******s
发帖数: 9638 | 7 还是让我们来做选择题：
1. Stroke， ipsilateral horner's with contralateral hemiparesis
2. Cervical myelopathy (primary or secondary), right sided weakness and left
sided horner's
3. Pharmacological pupilary changes and cervical myelopathy causing right
arm weakness.
4. Uncal herniation.
5. Something else. |
s******t
发帖数: 579 | 8 are the eyelids symmetrical?
What is the observation of the DTRs on both arms?
Is 1mm pupil saying meiosis?
Is respiratory failure central or peripheral?
Thanks! |
A*******s
发帖数: 9638 | 9 No ptosis。
Cocaine test is positive（dilated）。
DTR 2/4
She has COPD.
And she has glaucoma。
【在 s******t 的大作中提到】
: are the eyelids symmetrical?
: What is the observation of the DTRs on both arms?
: Is 1mm pupil saying meiosis?
: Is respiratory failure central or peripheral?
: Thanks!
|
s******t
发帖数: 579 | 10
r/o Horner's symdrome
r/o stroke?
respiratory failure is not from Uncal herniation.
close angle glaucoma can cause a fixed, mid-dilated pupil. We need to
measure the intraocular pressure for possible acute close angle glaucoma.
How about glaucoma and/or pharmacological papillary changes and cervical
myelopathy causing right arm weakness?
Is anti-M used for the biPAP?
Is right arm weakness new or residual symptom?
【在 A*******s 的大作中提到】
: No ptosis。
: Cocaine test is positive（dilated）。
: DTR 2/4
: She has COPD.
: And she has glaucoma。
|
A*******s
发帖数: 9638 | 11 You got the right answer.
The family brought in her eyedrops for glucoma and the nurse only put the
drops in her left eye. That's why her left pupil is constricted and right
pupil appeared to be bigger than normal that family usually sees.
Her right arm weakness is from surgery and myelopathy.
The lesson we learn from the case is: for the anisocoria, the very first
step is to make sure this is not a pharmacological pupil. Since this patient
has a history of glaucoma, what I did was to pick up the phone and call the
family.
How about glaucoma and/or pharmacological papillary changes and cervical
myelopathy causing right arm weakness?
Is anti-M used for the biPAP?
Is right arm weakness new or residual symptom?
【在 s******t 的大作中提到】
:
: r/o Horner's symdrome
: r/o stroke?
: respiratory failure is not from Uncal herniation.
: close angle glaucoma can cause a fixed, mid-dilated pupil. We need to
: measure the intraocular pressure for possible acute close angle glaucoma.
: How about glaucoma and/or pharmacological papillary changes and cervical
: myelopathy causing right arm weakness?
: Is anti-M used for the biPAP?
: Is right arm weakness new or residual symptom?
|
s******t
发帖数: 579 | 12 Thank you so much for the interesting case and for your explanation!
patient
the
【在 A*******s 的大作中提到】
: You got the right answer.
: The family brought in her eyedrops for glucoma and the nurse only put the
: drops in her left eye. That's why her left pupil is constricted and right
: pupil appeared to be bigger than normal that family usually sees.
: Her right arm weakness is from surgery and myelopathy.
: The lesson we learn from the case is: for the anisocoria, the very first
: step is to make sure this is not a pharmacological pupil. Since this patient
: has a history of glaucoma, what I did was to pick up the phone and call the
: family.
:
|
