CASE 1

A 40-year-old female dental hygienist tells you she has numbness and a burning sensation in her
right hand that has been bothering her for > 1 month. She has no history of injury to that hand.

1. What are the possibilities and what additional information do you need to narrow
this down?

2. What neuro do we need to know to be able to address this person’s problems?

3. What tests will you do?

4. What are the possible treatments to consider?

CASE 1B

A 40-year-old female dental hygienist tells you she has severe pain and a burning sensation in
her right hand that has been bothering her for > 6 months. She has a history of a right wrist
fracture with cast removal about 6 months ago.

1. What additional information do you need?

2. What testing will you do?

3. What neuro do you need to know to be able to address this person’s problem?
 Case Set 2

CASE 2A

Your patient is a 19-year-old male who was involved in a motor vehicle accident 6 weeks ago,
sustaining a complete SCI at level C6. He was discharged from the acute care facility 2 weeks
ago and is currently undergoing inpatient rehabilitation.
He was told that his legs are paralyzed because of his injury, but he has noticed thathis legs move
quite a lot now, especially when he is attempting to transfer or move in his wheelchair. He has
asked you if this is a sign he is recovering.

1. What information do you need to verify before answering him?

2. What assessments/ tests might you do?

3. What neuro do you need to know to understand why this is happening? How would
you explain it to him?

4. What are the functional implications?

CASE 2B

Your patient is a 19-year-old male who was involved in a motor vehicle accident 6 weeks ago,
sustaining a complete SCI at level C6. He was discharged from the acute care facility 2 weeks
ago and is currently undergoing inpatient rehabilitation.
During therapy today this patient has complained of a pounding headache. You notice that his
face has begun to sweat profusely, and his skin is flushed.

1. What additional information do you need in order to establish what is happening?

- Do they have any lines such as catheters, IVs, etc.

- What position were they in when it happened?
- Was there a change in vital signs?
- What was the patient doing during the onset of symptoms?

2. What neuro do you need to know to understand this problem?

- Symptoms of autonomic dysreflexia

- Distribution of sensation
- General knowledge of secondary complications to SCI

3. What is the appropriate response?

- Check for noxious stimuli

- Sit them upright
- Wait for vitals to stabilize
CASE 2C

Mae is an 84-year-old resident in a Skilled Nursing Facility (SNF) who complains of dizziness
and lightheadedness, making her feel like she is about to fall. She has not fallen, but visiting
family members are concerned that she seems unsteady on her feet especially when she gets out
of bed, and also when she first stands up from her chair. She spends much of her day lying in bed
or sitting in her chair and is ambulatory for short distances with a wheeled walker.

1. What are possible causes? (Considering her age, come up with 5-6)

2. What additional information do you need, to narrow down the possibilities?

3. What testing would be included in a detailed workup?

4. If you determine that the problem occurs primarily when going from a lying to
standing position, and then resolves after a period of a minute or so, what is the most
likely cause? What neuro do you need to know to understand this condition? (Why
doesn’t everyone get lightheaded when they stand up?)
 5. What strategies can be recommended to help with this problem?

Case Set 3
CASE 3A

Mr. Armstrong is a 71-year-old R-handed man who had a R MCA ischemic CVA three months
ago. He is currently enrolled in a rehab program that requires him to wear a mitt on his R hand
for most of his waking hours. His family members are very skeptical and are demanding an
explanation of why you want to make this man even less independent than he already was by
taking away use of his “good” arm.

1. What neuro do you need to know to understand his current condition?

2. What neuro do you need to know to explain the treatment described?

CASE 3B

Joanna is a bright 13-year-old with a diagnosis of hemiplegic CP due to a neonatal R MCA

ischemic stroke. Her main problem is severe spasticity in her L arm. She is ambulatory and
attends regular school. At an outpatient appointment today, she stated that she thinks she is due
for some Botox. Does this seem reasonable?

1. What neuro do you need to know to understand this girl’s condition?

2. What neuro do you need to know in order to address her concerns about
needing Botox?

a. What does Botox do?

b. What other options are there? How do they work?

3. How are management and expected outcomes of pediatric stroke different from
adult?
CASE 3C

Parents of a 2-year-old brought their daughter for assessment by a pediatric neurologist because
they noticed that she is still crawling when playmates her age are already walking. She has no
other signs of delayed development, verbally, cognitively, or socially, but her motor skills are far
behind those of her peers. The neurologist has diagnosed mild spastic diplegic cerebral palsy.

1. What do you need to know to understand why this diagnosis was made at this time?
Why wasn’t it made sooner? What is the name of this phenomenon? Give other examples.

2. Describe how you would assess the tone in her limbs. What would you expect to find?
What neuro do you need to know to explain these findings?

3. The neurologist has told the parents that cerebral palsy is due to nonprogressive
damage in the brain. What does that mean? How would that be different from progressive
damage? Give examples.

4. OT has been asked to provide suggestions for maximizing this child’s motor
development. What kinds of things might be beneficial and why?

Case Set 4
CASE 4A
Three patients who have had strokes were asked to describe the following image.

Patient A’s description:

OK. Uh... water, uh ... leaking, uh, from sink, uh. Window... seems... to... be... o-pen, uh. Outside view... of
...the next house, uh. See... bushes... uh, trees and walk... uh ... way and ... grass ...and, uh ... kids... uh.
Going... to ... fall ... off ... the ... stool, and, uh ... he’s, uh ... taking cookies ... and, uh ... and a housewife,
uh ...standing ... uh, in a ... puddle ... of water, and, uh ... boy, uh ... handing ... cookie ... to ... girl, and,
uh, ... she... seems ... to ... be finding ... the ... her mouth, uh... sss, uh. Two cups, uh ... plates, uh.
Housewife, uh...drying dishes, uh. Curtains, uh. That’s, uh... uh. Full cookie jar... and, uh... and a lid,
uh... leaning on...cans... cookie jar. Pretty much. OK? (Henderson, 1985)

Patient B’s description:

“Well this is mother is away here working her work out of here to get her better, but when she’s
looking, the two boys looking in the other part. One their small tile into her time here. She’s working
another time because she’s getting to. So two boys work together and one is sneaking around here
making his work and his further funnas his time he had.” (Goodglass & Kaplan, 1972)

1. What disorder is being demonstrated?

2. What neuro do you need to know to be able to explain the causes and the differences
between the 2 examples?

3.Which is likely to be more debilitating? Why?

Patient C had no problems describing what she saw. However, you found it very curious that
Patient C only described the woman at the sink and the view out the window but did not mention
the children getting into the cookie jar.
1. Discuss 2 possible causes for Patient C not mentioning that part of the image?
2. Is there any additional testing you would like to do?
3. Compare these 2 conditions in terms of mechanism, prognosis, and management

CASE 4B

Mr. Fallon is a 38-year-old man with a 10-year history of relapsing remitting MS. He is currently
hospitalized in a flare up. His primary concern is his inability to walk because of poor balance
and coordination.

1. What neuro do you need to know to understand this man’s balance and
coordination problems?

2. What assessments/tests would be appropriate to do?

3. Suggest 3 other potential reasons for walking problems in people with MS and
identify what the neurological basis is for them occurring in MS.
CASE 4C

You were asked to see a 61-year-old woman with Parkinson’s Disease who was admitted to
hospital following a fall at home. She did not sustain any fractures.
The neurology resident has written discharge orders indicating the patient is ready to go home,
and is safe and independent with functional mobility and transfers; however, you found that she
was only able to stand and walk with maximal assistance and showed severe bradykinesia and
freezing of gait.

1. What neuro do you need to know to explain these two different assessment findings?

2. What should you include in your assessment of this patient?