HPI
A 6 yo girl has been admitted for pneumonia. You are asked to see her when someone notes that she has clonus at the ankle. Her parents tell you that she has been having slurred speech for the last 2 weeks. She occasionally had double vision starting about 3 weeks ago but it has actually gotten better.
PMH
: Unremarkable including birth and developmental history.
PSH
: None
Medications: None
Allergies: None
SH: She lives with her parents. Both her parents are migrant farm workers.
PE
Gen: : Ill appearing child, T 38 other vital signs are normal
CV: Regular rate and rhythm
Pulm: Bronchial breath sounds on the right
Abd: Good bowel sounds, soft, nontender nondistended, no hepatosplenomegaly
Ext: No cyanosis, clubbing or edema
NEURO
- MS: Cranky child who does not wish to cooperate
- CN: Pupils reactive but right pupil is smaller than the left, fundi show sharp disc margins, she does not bury her sclera of her right eye with lateral gaze to the right (mild right abducens palsy), her right eye does not shut as tightly as her left when she cried and her nasolabial folds are asymmetric with the left being deeper than the right (mild right facial weakness), gag is intact
- Motor: She moves all her extremities but has more spontaneous movements left side (mild right hemiparesis), her reflexes are brisk in all four extremities with a few beats of clonus on the left and sustained clonus on the right
- Sensory exam: She withdraws all extremities when you poke her with a pin but again moves the left side more readily
- Gait/Cerebellar: She does not cooperate for finger to nose or gait testing but is able to swat you away pretty accurately with her left arm
Study Questions:
- Summarize the history and exam:
- Localize the lesion
- Discuss the differential diagnosis by pathophysiology
- What diagnostic tests would you request to evaluate your hypothesis and what do you expect to find?
- How might the pneumonia be related to her symptoms?
- Pick the diagnosis that you think is most likely and briefly discuss.
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