Case Study The Neurologic System By Janice, Margaret and Tanya

Question # 1 Could Mr. C.'s foot numbness be related to his stroke? What other causes could there be for this pattern of numbness? (From the last unit, remember his history of alcohol intake, Type 2 diabetes and colorectal cancer.)

No we do not think the numbness is related to his stroke because it is present in both feet. Numbness in the feet can be caused by anything that upsets the nerve cell's delicate chemistry. Such diseases include diabetes, vitamin deficiencies, liver or kidney disease, cancer, Lyme disease and many drugs. In this country, diabetes is the most common cause of foot numbness, the numbness usually occurs when sugars are out of control. We think Mr.C has peripheral neuropathy.

What is Peripheral Neuropathy(PN) ? Peripheral neuropathy describes damage to the peripheral nervous system, the vast communications network that transmits information from the brain and spinal cord (the central nervous system) to every other part of the body. Peripheral nerves also send sensory information back to the brain and spinal cord, such as a message that the feet are cold or a finger is burned. Damage to the peripheral nervous system interferes with these vital connections. Like static on a telephone line, peripheral neuropathy distorts and sometimes interrupts messages between the brain and the rest of the body.

Taking a closer look at PN Peripheral neuropathy(PN) affects 10 to 20 million people in the U.S, including ten per cent of all people who have diabetes. This condition has numerous causes and can be associated with diseases such as HIV, alcoholism, and lupus, and may result from treatments for other medical conditions, such as cancer and chemotherapy. Cancers and benign tumors (Mr.C has reoccurring CA) can infiltrate or exert damaging pressure on nerve fibers. Toxins can also cause peripheral nerve damage. Certain anticancer drugs, anticonvulsants, antiviral agents, and antibiotics have side effects that can include peripheral nerve damage, thus limiting their long- term use. (Mr. received chemotherapy in the past).

Mr. C. History If you recall Mr. C has had chemo in the past for his colon cancer, he is a type two diabetic with sugars out of control and does have a history of excessive alcohol use. Also he now has CA of the liver. Diabetes Mellitus is characterized by chronically high blood glucose levels (which Mr. C has) and is a leading cause of peripheral neuropathy in the United States.

Peripheral neuropathy may be either inherited or acquired. Causes of acquired peripheral neuropathy include physical injury (trauma) to a nerve, tumors, toxins, autoimmune responses, nutritional deficiencies, alcoholism, and vascular and metabolic disorders. Systemic diseases disorders that affect the entire body often cause peripheral neuropathy. These disorders may include metabolic and endocrine disorders. Nerve tissues are highly vulnerable to damage from diseases that impair the body's ability to transform nutrients into energy, process waste products, or manufacture the substances that make up living tissue.

Characteristics displayed ! Diabetes Mellitus leads to blood vessel constriction. Vascular damage and blood diseases. decrease oxygen supply to the peripheral nerves lead to serious damage to or death of nerve tissues. Alcoholism cause widespread damage to nerve tissue. Thiamine deficiency causes painful neuropathy of the extremities.

Question #2 Given Mr. C.'s age (70) and multiple medical conditions, you wonder if he could have a subdural hematoma. Why would he now, when it is weeks after the head injury?.

Mr. C probably had a right sided stroke previously as he has left sided weakness. Effects of right hemisphere strokes Weakness or paralysis on the left side of your body Vision problems. Problems distinguishing distance, depth, between up and down, or between front and back. This can make it hard to pick up objects, button a shirt, or tie your shoes. Problems understanding maps. Problems with short-term memory. You may be able to remember something that happened several years ago, but not something you did a few minutes ago. Forgetting or ignoring objects or people on your left side (this is called neglect). You may even ignore your own left arm or leg. Judgment difficulties, such as acting impulsively or not realizing your own limitations.

Subdural hematomas Can occur after a very minor head injury, especially in the elderly. These may go unnoticed for many days to weeks, and are called "chronic" subdural hematomas.(as in Mr.C's case) With any subdural hematoma, tiny veins between the surface of the brain and its outer covering (the dura) stretch and tear, allowing blood to collect. This collection of blood then forms over the surface of the brain. In a chronic subdural collection, blood leaks from the veins slowly over time. A subdural hematoma is more common in the elderly because of normal brain shrinkage that occurs with aging. This shrinkage stretches and weakens the bridging veins. These veins are more likely to break in the elderly, even after a minor head injury. Mr. C reported that he fell and his head hit the floor prior to leaving the hospital. This could have likely caused a subdural hematoma. Mr. C may also be on anticoagulant therapy from his previous stroke which could worsen the hematoma.

Subdural Hematomas Risks include: Chronic heavy alcohol use Chronic use of aspirin, anti-inflammatory drugs such as Ibuprofen or blood thinning (anti-coagulant) medication Diseases associated with blood clotting problems Head injury Old age Symptoms : Confusion Decreased memory Difficulty speaking or swallowing Difficulty walking Headache Seizures Weakness or numbness of arms, legs, face

A subdural hematoma is an emergency condition! Emergency surgery may be needed to reduce pressure within the brain. This may involve drilling a small hole in the skull, which allows blood to drain and relieves pressure on the brain. Large hematomas or solid blood clots may need to be removed through a procedure called a craniotomy, which creates a larger opening in the skull. Medicines used to treat a subdural hematoma depend on the type of subdural hematoma, the severity of symptoms, and how much brain damage has occurred. Diuretics and corticosteroids may be used to reduce swelling. Anti- convulsion medications such as phenytoin may be used to control or prevent seizures.

Please feel free to ask questions or add to our discussion Thank You Group E

References Engehard, H., Sinson, G.P., & Reiter, T.G. (2007). Subdural hematoma. Retrieved January 26, 2007 from overview.overview Gould, B. (2006). Pathophysiology for the Health Profession (3 rd ed). Philadelphia: Elsevier Inc. McCance, K. L., Huether, S.D. (2006). Pathophysiology: the biologic basis for disease in adults and children (5 th ed.) Mosby. St. Louis, MS Cancersymptoms.org (2009). Causes of cancer-related peripheral neuropathy. Retrieved January 26, 2009 from

National Institute of Neurological Disorders and Stroke (2008). Peripheral neuropathy fact sheet. Retrieved January 26, 2009 from htm#