Case Studies

A 12-year-old boy began to complain of frequent headaches 4 months before his hospital
admission. On the day of his admission, he had a major motor seizure, which his parents
observed. During the seizure he lost bladder and bowel control. On physical examination he
appeared to be in deep postictal sleep. He had no focal neurologic signs. On examination of
the optic fundi, no evidence of papilledema was found.

Studies Results

Routine laboratory work Within normal limits (WNL)

Skull X-ray study, p. 1062 No evidence of skull fracture

Lumbar puncture, p. 651

Opening pressure 250 cm H20 (normal: <200 cm H2O0)

Closing pressure 220 cm H2O (normal: <200 cm H20)

Cerebrospinal fluid (CSF)

examination, p. 651

Blood Negative

Color Clear

Cells

Lymphocytes 0-2/mm3

(normal: <5/mm3

)

Polymorphonuclear leukocytes None (normal: none)

Protein 120 mg/dL (normal: 15-45 mg/dL)

Glucose 50 mg/dL (normal: 50-75 mg/dL)

Cytology Questionably malignant cells

Serologic test for venereal disease Negative (normal: negative)

Electroencephalography (EEG), p. 549 Focal slowing of wave pattern in posterior aspect of
the cerebrum (normal: regular, rhythmic,

Brain scan, p. 785 Increase in radioactivity in the posterior aspect of

the brain (normal: homogenous and minimal

uptake of radioactive material)

Cerebral angiography, p. 988 Neovascularity (tumor vessels) in the posterior

aspect of the brain, involving the cerebellum

and the occipital lobe of the cerebrum (normal:

normal carotid vessels and terminal branches)

Magnetic resonance imaging (MRI) of

the brain, p. 1106

Tumor of the cerebellum extending into the

posterior cerebrum

Computed tomography (CT) scan of

the brain, p. 1026

A soft tissue mass arising out of the cerebellum and

invading the occipital lobe of the cerebrum

Case Studies 2

Diagnostic Analysis

The skull X-ray study ruled out the possibility of a skull fracture as the cause of the boy’s
problem. Lumbar puncture excluded the possibility of meningitis or subarachnoid
hemorrhage; however, the high protein count and questionable positive cytology indicated a
possible neoplasm. An EEG located an area of nonspecific abnormality in the posterior
aspect of the brain. Brain scanning, cerebral angiography, and CT scanning indicated a
posterior fossa tumor. These tests are mentioned in this case study mostly for historical
interest. Under most circumstances, this young boy would have a MRI of the brain early in
the diagnostic period.

Because of these findings, the patient underwent a craniotomy. In many centers, this young
boy would have a nonoperative stereotactic brain biopsy instead of a craniotomy. An
invasive medulloblastoma was found to be arising from the patient’s cerebellum and
involving the occipital lobe of the cerebrum. The tumor was unresectable. Postoperatively,

the patient was given phenytoin (Dilantin) and radiation therapy to the involved area. A
chemotherapy regimen was administered. The patient’s tumor did not respond to the therapy,
and he died 4 months after the onset of disease.
Critical Thinking Questions

  1. What are the major assessments that the nurse should make during seizure activity?
  2. Why is the EEG a priority study for patients with seizure disorders?
    Thyroiditis
    Case Studies
    The patient, a 23-year-old woman, has had a bout of flulike symptoms over the past few
    weeks. Most recently, she has become increasingly tired. She is taking birth control pills to
    control her menses. Her anterior neck became painful during the past few weeks. The
    physical examination results reveal that her thyroid is diffusely enlarged and mildly tender.
    Studies Results
    Routine laboratory tests Within normal limits (WNL)
    Total thyroxine (T4), p. 497 8 meg/dL (normal: 5-12 meg /dL)
    Free T4 0.5 ng/dL (normal: 0.8-2.7 ng/dL)
    Free T4 index 0.4 ng/dL (normal: 0.8-2.4 ng/dL)
    Triiodothyronine (T3), p. 506 52 ng/dL (normal: 70-205 ng/dL)
    Thyroxine-binding globulin (TBG), p.
    495
    12 mg/dL (normal: 1.7-3.6 mg/dL)
    Thyroid stimulating hormone (TSH),
    p. 486
    32 microunits/mL (normal: 2-10 microunits/mL)

Thyroid ultrasound, p. 895 Enlarged gland; normal shape and position of the

thyroid gland

Thyroid antibodies

Antithyroglobulin antibody, p. 102 1:250 (normal: titer <1:100)

Antithyroid peroxidase antibody, p.

104

1:500 (normal: titer <1:100)

Thyroid-stimulating

immunoglobulins, p. 491

Negative

Diagnostic Analysis

Total T4 measures protein-bound and unbound T4. Because the patient was taking birth
control pills, her TBG was elevated; therefore, her total T4 was normal. Free T4 and FT4
index tests measure unbound T4. When the free T4 and the FT4 index were measured, they
were found to be low, indicating that the patient had hypothyroidism. The TSH level was
elevated because of primary failure of the thyroid. The thyroid antibodies were elevated,
indicating that the patient had Hashimoto thyroiditis. Her long-acting thyroid stimulator
(LATS) levels were normal, discounting Graves disease as a cause of her diffusely enlarged
thyroid. Her thyroid ultrasound and scan failed to show any localized, defined tumor.

The patient was started on thyroid replacement therapy, and her TSH level returned to
normal. Over the next few weeks, she felt markedly better. Her thyroid pain and tiredness
disappeared.

Critical Thinking Questions

  1. Why were the thyroid antibodies important in this patient’s diagnosis?
  2. What symptoms might she experience if too much thyroid replacement medication were
    administered?

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