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Posterior Fossa Syndrome

Initial Exam

During Katie's initial examination, the following results were found:

• HEENT, neck, chest, and abdomen unremarkable
• Heart assessment showed a mild sinus arrhythmia with HR 90-110
• Initial manual muscle testing grossly tested at 4-5/5 bilaterally
• Deep tendon reflexes were 1-2+ (hyporeactive-normal) bilaterally
• Negative Babinski and ankle clonus
• Pupils 5 mm, briskly reactive to direct light
• Conjugate gaze and full extraocular movement noted, no nystagmus
• Face is symmetric, palate raised, tongue unremarkable
• Voluntary movement of all extremities noted
• Exhibited mild to moderate dysmetria (over or underestimates the ROM needed to place limbs correctly during a voluntary movement) & dysdiadochokinesia (inability to perform rapidly alternating movements) in left arm & leg

Blood Testing

Patient's results compared to normal values

A plain CT was performed on the day of admission and showed a tumor in the posterior fossa of the brain, with obstructive hydrocephalus.

Presumed diagnosis: obstructive hydrocephalus with posterior fossa astrocytoma. Surgery was planned to be performed in two days.