Question

Two physicians are finishing their rounds when a paramedic brings a patient in the emergency room. The senior paramedic, Jim Morrison, reported that the patient was swimming at the local quarry and did a forward flip into the water, striking some submerged rocks. "Which part of his body struck the rocks?" asked Dr. Carter. "He was in a hyperflexed-tucked-position when he hit the rocks, lacerating the right side of his head and neck and upper back. The patient indicated he had severe pain upon impact and loss of sensation and movement in his arm and leg. He may have lost consciousness, but he's not sure. He also complains of a severe headache, dizziness, and nausea. When we arrived at the scene we immobilized, stabilized and transported him immediately," Jim explained. Looking at the patient, Jim continued. "His name is Mike Smith, and he's 22 years of age. His vital signs include slightly lowered blood pressure (100/70), heart rate of 75 beats per minute, respiration normal, and he is conscious and alert." As the patient was being prepped for examination, Dr. Carter and Dr. Green discussed how they should approach their evaluation. Dr. Carter started by saying,"After seeing the head wound and the amount of blood loss, and hearing his complaints, I want to confirm my suspicion that this patient has a brain injury." Dr. Green disagreed: "I think that the other signs and symptoms indicate a spinal cord injury, and that's what we should investigate." The following table summarizes the findings of the evaluation, which included a physical exam, X-rays, magnetic resonance imaging (MRI), and neurological tests.
Summary of Diagnostic Testing for Mike Smith
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
Motor Testing -Decreased strength and movement of the right upper/lower extremities during muscle testing -Decreased strength and movement of left abdominal muscles -Absence of triceps and biceps reflexes in the right upper extremity -Abnormal response of patellar, Achilles (hyper) reflexes in the right lower extremity -Positive Babinski sign on the right foot -Abnormal cremasteric reflex in the right groin region
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 present in the skull -Fracture in the 7th cervical vertebra -Significant swelling present in the spinal canal in the C7-T2 region Spinal cord appears to be intact
Which of the Doctors (Carter or Green) are correct with the diagnosis. Please, explain why you chose one or the other.  

Answer 1

Ans - Dr Green is right about diagnosis -

Examination findings

His vital signs include slightly lowered blood pressure (100/70), heart rate of 75 beats per minute, respiration normal, and he is conscious and alert.

Sensory Testing - Sensory involvement is suggestive of Spinal cord involvement.

1. Decreased sensation to touch, pressure, and vibration in the right upper/lower extremities

2. Decreased temperature discrimination (cold vs. warm) in the left upper/lower extremities

Motor Testing - Side of Injury and weakness is same wjich indicate involvement of spinal cord in brain injury the side of weakness is opposite to the side of injury as there is crossing of corticospinal fibres at medulla oblongata

1. Decreased strength and movement of the right upper/lower extremities during muscle testing

2. Decreased strength and movement of left abdominal muscles.

3. Absence of triceps and biceps reflexes in the right upper extremity.

4. Abnormal response of patellar, Achilles (hyper) reflexes in the right lower extremity

5. Positive Babinski sign on the right foot

6. Abnormal cremasteric reflex in the right groin region

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 present in the skull -Fracture in the 7th cervical vertebra -Significant swelling present in the spinal canal in the C7-T2 region Spinal cord appears to be intact