Case Index

CASE STUDIES IN NEUROLOGY
Week 4 X-tra Credit Case

You are asked about the following patient and only limited information is available:

CC: staggering HPI

30 yo RH man with history of difficulty walking for the last several months. He reports that he is getting worse and has been seen in the emergency room multiple times but not really had any tests previously. He drinks a six-pack of beer or so daily and has been in multiple minor motor vehicle accidents over the last several years.

PMH : As above

PSH : None

Medications: None

Allergies: NKDA



PE
  • Gen: No acute distress, afebrile
  • CV: regular rate and rhythm
  • Pulm: clear to ascultation
  • ABD: good bowel sounds, soft, nontender nondistended, no hepatosplenomegaly
  • Ext: no cyanosis, clubbing, or edema

    NEURO
    • "Awake, moves all four, staggering gait"


    Study Questions:
    1. What pathophysiology seems most likely at this point?



    You are told the patient had a head CT that is normal and does not show cerebellar atrophy.
    Study Questions:
    1. Are you surprised?

    You go to see the patient and obtain additional history and examine him:
    The patient has had urinary incontinence for a few weeks. When he needs to urinate, he has to go right away. He cannot hold it and his fingers have been stiff lately so he has trouble undoing his fly in time.
    Neuro:
    1. MS: awake, alert, attentive, oriented
    2. CN: Normal
    3. Motor: Weakness of the deltoids bilaterally as well as distal upper extremity muscles. Also some weakness of the lower extremities but not as severe as the upper extremities. Spasticity of the upper and lower extremities. Very brisk DTRÕs at the biceps, brachioradialis, triceps, patellar and Achilles tendons with clonus at the ankles bilaterally and extensor plantar responses. HoffmanÕs reflexes present in both upper extremities.
    4. Sensory: Inconsistent findings but vibration seems intact.
    5. Cerebellar: No dysmetria
    6. Gait: Stiff legged awkward gait.
    • Study Questions:
    1. Summarize the history and exam.
    2. Given the additional history and exam, can you localize the lesion? Are other historical details that might be useful? Are there other things on the exam that would help to localize the lesion better? Where does the lesion localize to based on the information you have?
    3. Discuss the differential diagnosis by pathophysiology
    4. What diagnostic tests would you request to test your hypothesis and what do you expect to find.



    The patient had a procedure. The weakness and spasticity of the extremities have improved but the patient now notes that whenever he sticks his tongue out it points to the right.

    Study Questions:
    1. What has happened? Localize the new symptom