Case #383: MRI brain, 11/8/94(Atrophy Left fronto-temporal lobe): HCT ,1/5/95(Left frontal SDH)
CC: Fall with subsequent nausea and vomiting.
Hx: This 52 y/o RHM initailly presented in 10/94 with a two year hisotry of gradual progressive difficulty with speech. He "knew what he wanted to say, but could not say it."
His speech was slurred and he found it difficult to control his tongue. Examination at that time was notable for phonemic paraphasic errors, fair repetition of short phrases with decreased fluency, and slurred nasal speech. He could read, but could not write. He exhibited facial-limb apraxia, decreased gag reflex and positive grasp reflex. He was thougth to have possible Pick's disease vs. Cortical Basal Ganglia Degeneration.
On 11/18/94, he fell and was seen in Neurology clinic on 11/23/94. EEG showed borderline background slowing and no other abnormalities. An MRI on 11/8/94, revealed mild atrophy of the left temporal lobe. Neuropsychological evaluations were obtained on 10/25/94 and 11/8/94. These were consistent with progressive aphasia and apraxia with relative sparing of nonverbal reasoning.
He reported consuming 8 beers on the evening of 1/1/95. On 1/2/95, at 9:30AM, he fell forward while stading in his kitchen and struck his forehead on the counter top, and then struck his occiput on the floor. He subsequently developed nausea and vomiting, tinnitus, vertigo, headache and mild shortness of breath. He was taken to the ETC at UIHC. Skull films were negative and he was treated with IV Compazine and IV fluid hydration and sent home. His nausea and vomiting persisted and he became generally weak. He returned to the ETC at UIHC on 1/5/95. HCT scan revealed a right frontal SDH containing signs of both chronic and acute bleeding.
PMH: 1)fell in 1990 from 15 feet up and landed on his feet sustaining crush injury to both feet and ankles. He reportedly had brief loss of consciousness with no reported head injury.
2)Progressive aphasia. In 10/93, he was able to draw blue prints and write checks for his family business, 3) Left frontoparietal headache for 1.5 years prior to 10/94. Headaches continue to occur once a week, 4)right ankle fusion 4/94, right ankle fusion pending at present.
FHx: No neurologic disease in family.
SHx: Divorced and lives with girlfriend. One child by current girlfriend. He has 3 children with former wife. Smoked more than 15 years ago. Drinks 1-2 beers/day. Former Iron worker.
EXAM: BP128/83, HR68, RR18, 36.5C. Supine: BP142/71, HR64; Sitting: BP127/73, HR91 and lightheaded.
MS: Appeared moderately distressed and persistently held his forehead. A&O to person, place and time. Dysarthric and dysphagic. Non-fluent speech and able to say single syllable words such as "up" or "down". He comprehended speech, but could not repeat or write.
CN: Pupils 4/3.5 decreasing to 2/2 on exposure to light. EOM were full and smooth. Optic disks were flat and without sign of hemorrhage. Moderate facial apraxia, but had intact facial sensation.
Motor: 5/5 strength with normal muscle bulk and tone.
Sensory: no abnormalities noted.
Coord: Decreased RAM in the RUE. He had difficulty mmicking movements and postures with his RUE
Station: No truncal ataxia, but he had a slight RUE upward drift.
Reflexes 2/2 BUE, 2+/2+ patellae, 2/2 archilles, and plantar responses were flexor, bilaterally.
Rectal exam was unremarkable. The rest of the General Physical exam was unremarkable.
HEENT: atraumatic normocephalic skull. No carotid bruitts.
COURSE: PT, PTT, CBC, GS, UA and Skull XR were negative. HCT brain, revealed a left frontal SDH with acute and cronic componenets.
He was markedly orthostatic during the first few days of his hospital stay. He was given a 3 day trial of Florinef, which showed mild to moderate improvement of his symptoms of lightheadedness. This improved still further with a trial of Sigvaris pressure stockings. A second HCT was obtained on 12/10/94 and revealed decreased intensity and sized of the left frontal SDH. He was discharged home.
His ideomotor apraxia worsened by 1/96. He developed seizures and was treated with CBZ. He progressively worsened and his overall condition was marked by aphasia, dysphagia, apraxia, and rigidity. He was last seen in 10/96 and the working diagnosis was CBGD vs. Pick's Disease.
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