case report of a neurological patient

Case report

Case Report
The essay is a case report of a neurological patient seen during the module or in your own clinical practice (with the prior agreement of Dr ???. The essay should demonstrate an understanding of how the history and examination findings are used, first, in localisation of brain lesions and, second, in generating hypotheses that can be used to guide neuropsychological assessment.

The case report should include:

I. Clinical presentation:

Relevant history (presenting symptoms, onset/progression, associated medical conditions relevant to the current problem).

Neurological examination findings: e.g., motor (strength, coordination, reflexes), somatosensory, visual, eye movements, etc…

Cognitive examination findings.

Neuroradiological findings

In some cases, there will be limited or no information in some of the above sections.

Guidance Note: A well written case report should not simply state your interpretation of the findings, but paint a vivid picture of what you observed. For example, if you are describing an aphasic patient who has anomia, you will not only want to say whether the patient makes semantic or phonemic paraphasic errors, but also give some examples. Similarly, it is not adequate to say that the patient ‘had apraxia’. Describe how it was tested for and what was observed.

Ideally, you should base this section on what you observed during the examination, from your notes. The key objective here is to demonstrate your knowledge and understanding of key facts and principles.

II. Analysis of the Case

This should consider:

Based on the history and examination, what is the most likely diagnosis? If the diagnosis is not obvious, what is the differential diagnosis (what aetiologies are to be considered?)

How each finding on the neurological and mental status examinations is used to infer possible lesion localisation(s).

Guidance Note: In discussing localisation, you will want to demonstrate a solid grasp of functional neuroanatomy. For example, if a patient is weak and has increased reflexes on one side of the body, you can conclude that there is damage somewhere in either the primary motor cortex or the cortico-spinal tract. A bald statement to this effect, however, only demonstrates that you have memorised this as a fact – not that you know anything about the origin of the cortico-spinal tract or its anatomy. An optimal treatment would discuss this anatomy and where in the brain the lesion could be located.

III. Discussion

Discuss the case with reference to literature on the patient’s neurological and neuropsychological deficits. If a patient has multiple problems (e.g., visual agnosia and Balint’s syndrome), you may chose to concentrate on one. Suggest a research question that could be addressed using the patient as a participant.

(3000 words)

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