Read the Testing the Nervous System case study.

Answer each question and write a report for the case study.

1. Which of the test results indicated a brain injury and why?
2. Which of the test results indicated a spinal cord injury and why?
3. Are there any cranial nerves involved? Describe which cranial nerves could be involved.
4. Explain why the reflexes were hyperactive and the presence of the Babinski reflex.

Case Study

The case is based on a case from the National Center for Case Study Teaching in Science and modified/rewritten by Dr. Bruce Forciea.

Dr. Mary Smith and Dr. Ashley Peters were beginning their ER residency at ACME Memorial Hospital. They had been close friends throughout medical school and were looking forward to helping each other through the challenges of clinical work. They had just completed a 16-hour shift and were sitting down to enjoy a cup of bitter vending machine coffee when nurse Cassidy burst into the break room.

"I wouldn't get too comfortable," said nurse Cassidy. "A call just came in; paramedics are bringing in a 19-year-old male with neuro injuries. Better drink up and get back to the ER."

The young doctors intercepted the paramedics wheeling in the teen. His eyes were wide open, and he struggled to speak with the neck brace anchoring his head.

"19-year-old male, BP 100/70, pulse 102 bpm, respirations elevated, conscious and alert. A head wound with significant loss of blood. Motorcycle versus car accident. Friends called 911. Loss of consciousness at the scene, loss of sensation and movement in right upper and lower extremities. We immobilized and stabilized him at the scene."

"So, what do you think?" said Dr. Smith. "I think we should rule out central nervous system/brain injury first?" said Dr. Peters.

"Actually, I disagree," said Dr. Peters. "I think we should evaluate the spinal cord and peripheral nervous system first."

"We'll do both," said Dr. Smith. "Let's get going."

The following table summarizes the ndings of the evaluation, which included a physical exam, x-rays, magnetic resonance imaging (MRI), and neurological tests.

Table 1. Summary of Diagnostic Testing for ER Patient

Sensory Testing

• Decreased sensation to touch, pressure, and vibration in the right upper/lower extremities
• Decreased temperature discrimination (cold vs. warm) in the left upper/lower extremities
• Numbness on the right cheek

Motor Testing

• Decreased strength and movement of the right upper/lower extremities during muscle testing
• Absence of triceps and biceps reexes in the right upper extremity
• Numbness on the medial portion of the right hand and forearm
• Abnormal response of patellar, Achilles (hyper) reexes in the right lower extremity
• Positive Babinski sign on the right foot
• Inability of patient to turn head to the right along with weak right trapezius muscle
• Weakness of right masseter muscle
• Mild blurred vision

General Examination

• Abnormal pupil response of right eye (constriction)
• Other vital signs within normal limits
• Cognitive testing normal (counts backward from 100 by 7s; knows name, date, place)

X-Ray and MRI Examination

• No fractures were present in the skull
• Fracture in the 7th cervical vertebra
• Signicant swelling present in the spinal canal in the C7-T2 region
• Spinal cord appears to be intact