Download London Cases - University of Michigan

NEUROLOGY CASES
(By Zach London and Aaron Boster)
Case 1:
A 72 year old retired beekeeper with a history of
hypertension presented with sudden onset of
word-finding difficulty and weakness of the right
arm that started approximately 45 minutes prior
to presentation. On examination his blood
pressure was 148/82 and heart rate was 80. His
speech was nonfluent, and he had difficulty with
both naming and repetition. He had a right facial
droop, and pronator drift of the right arm.
Case 2:
A 62 year old man said that he woke up with
difficulty seeing out of his left eye. He reported a
history of hypertension and paroxysmal atrial
fibrillation, but had not been taking any
medications. On examination, his blood pressure
was 180/94, and his heart rate was 125 and
irregular. The only neurologic abnormality on
examination was a left homonymous
hemianopia.
Case 3:
A 60 year old diabetic woman was brought to the
Emergency Room by paramedics. She stated that
when she woke up that morning and tried to get
out of bed, she fell down and was unable to get
up again. She had trouble moving her right arm
and leg. On examination, her blood pressure was
170/92 and her heart rate was 90. She was alert
and oriented, with normal speech and language.
She had hemiparesis involving the right face,
arm, and leg. Sensation was normal. She had an
extensor plantar response on the right.
Case 4:
An 80 year old man came to clinic reporting
episodic loss of vision in the left eye. He stated
that each episode began suddenly, and gradually
worsened over the course of 15-20 seconds, “like
a shade being drawn over the eye.” The visual
loss had always resolved completely within 5-10
minutes and was not associated with any pain or
other neurologic symptoms. His examination
was normal.
Case 5:
A 72 year old nun presented in the emergency
room with approximately 14 hours of symptoms.
Her friends stated that she was in her usual state
of health until the previous afternoon. She had
been bowling, and suddenly noted left-arm
weakness and difficulty walking. She tried to
“sleep it off” overnight, but her symptoms
continued the next morning, and her friends from
the convent brought her to the emergency room.
On physical examination, she was afebrile with a
blood pressure of 140/80 and a heart rate of 86.
She had a prominent carotid bruit on the right
side. Her left face, arm, and leg were weak,
although her face and arm were much weaker
than her leg. She had some decreased sensation
on the left side, and extinction of left-sided
stimuli to double simultaneous stimulation. She
had an incomplete left homonymous
hemianopsia and poor left conjugate gaze.
Case 6:
A 62 year old man with hypertension, diabetes,
and hyperlipidemia was walking into the VA
hospital, where he works as a custodian, when he
had the sudden onset of vertigo, nausea, and
hiccups. On physical examination, his blood
pressure was 180/100. He was noted to have left
facial numbness, as well as left ptosis and
miosis. He was dysarthric and had difficulty
swallowing. His left arm and leg were also
ataxic.
Case 7:
A 31 year old yoga instructor presented to the
emergency room at the urging of her husband.
She reported five days of pain in her left neck
and the back of her head that came on the day
after she underwent chiropractic manipulation of
her neck. She called the chiropractor, who told
her that her symptoms were caused by “her
nerves realigning themselves” and that she
needed more frequent manipulations. However,
over the last 24 hours, she had also begun to
experience some vertigo, nausea, and left facial
numbness. Her neurologic examination was
significant for decreased pinprick sensation in
the second division of the left trigeminal nerve.
She also had right beating nystagmus in all
directions of gaze and weakness of palate
elevation on the left. The examination was
otherwise normal.
Case 8:
A 58 year old man with a history of smoking,
hypertension, diabetes and TIAs presented with
six hours of numbness affecting his left face, arm
and leg. His examination was significant for a
blood pressure of 158/94, and decreased
sensation to all modalities on the left side. He
had no weakness or other neurologic deficits.
Case 9:
A 90 year old woman with a history of
hypertension and mild dementia stopped taking
her lisinopril approximately six months ago
because her doctor went out of town the week
she needed a refill. She presented to the
emergency room with headache, balance
problems, and incoordination of her limbs, as
well as some vertigo and nausea. On
examination, her blood pressure was 230/118,
and she was profoundly ataxic. Initially, she was
awake and alert, but over the course of the next
hour, she became progressively obtunded to the
point that she would not open her eyes and
would only moan when stimulated. CT scan of
the head showed a large hyperdensity in the
cerebellar vermis with obliteration of the fourth
ventricle and some evidence of cerebellar
tonsilar herniation.
Case 10
A 19 year old University of Michigan
cheerleader received a blow to the left temple
when he dropped one of the female cheerleaders
and her elbow collided with his head. He lost
consciousness briefly, but recovered fully. She
was taken to the emergency room to have her
elbow stitched up. Overcome with guilt, he
decided to drive her there. While they were in
the waiting room, he started experiencing a
severe headache. He was put into a room, but
when a nurse came to check on him 30 minutes
later he had impaired consciousness and dilation
of the left pupil.
Case 11
A 28 year old woman came into clinic with her
boyfriend, complaining of intermittent headaches
for almost three months. The headaches started a
day or two after one of her kickboxing students
kicked her in the head. Over the last few weeks,
the headaches have become more constant and
more severe to the point that she had to cancel
the rest of her kickboxing classes. Her boyfriend
stated that she was drowsy all the time, and
would sleep all day if not awakened. On
examination, she was irritable and would say
only that she had a headache. Her left face, arm,
and leg were moderately weak, and she had
hyperreflexia on the left side.
Case 12
A 17 year old boy was brought to clinic by his
father. The patient is a fullback for the local high
school team. Last season, he suffered multiple
minor head traumas, sometimes associated with
brief loss of consciousness and brief retrograde
amnesia. He reported that during the last two
months, this had been happening more
frequently, and the amount of trauma required to
bring on each episode was less and less. Once, he
was tackled and “blanked out” even though his
head barely hit the ground. His father stated that
his teachers had seen him “zone out” during
class. He came to the clinic because his coach
was threatening to cut him from the team.
Case 13
A 14 year old girl was run over by a float in the
4th of July parade in a small town. She lost
consciousness for several minutes. When she
woke up, she was paraplegic and had no feeling
in her lower extremities. She was initially
admitted to an outside hospital, but was
transferred to the University of Michigan after
about three weeks because of blood pressure
fluctuations. On physical examination, she had
normal strength in the upper extremities and 0/5
strength in both lower extremities. Pinprick
sensation was decreased below the level of the
umbilicus bilaterally. Reflexes were 2+ and
symmetric in the upper extremities, 3+ at the
knees, and 4+ at both ankles with sustained
clonus and bilateral extensor response to plantar
stimulation.
Case 14
A 36 year old HIV positive woman presented to
the Emergency Room complaining of severe
lower back pain and paresthesias in her buttocks
and legs. She had an episode of urinary
incontinence in the waiting room. On
examination, she was febrile (103.3) and
diaphoretic. Her low back was exquisitely
tender. Strength was 3/5 in both lower
extremities with bilateral extensor plantar
responses. Her white blood cell count was
26,000/uL.
Case 15
A 66 year old man underwent an elective repair
of a large abdominal aortic aneurysm. Three
days later, you received a call from the vascular
surgery service. They stated that the patient had
not moved his legs since waking up from the
surgery. On examination, he had a Foley catheter
in place. Strength was 5/5 in the upper
extremities and 0/5 in the lower extremities. He
had decreased pinprick sensation below the
midthoracic region bilaterally. Vibration and
position sense were intact throughout. Lower
extremity reflexes were brisk and symmetric, and
his toes were upgoing to plantar stimulation
bilaterally.
Case 16
A 23 year old man was in a motorcycle accident.
He was not wearing a helmet. He did not lose
consciousness. On presentation to the emergency
room, he complained of left shoulder pain and an
inability to move the fingers of his left hand. On
physical examination his right pupil was larger
than the left. He had a mild left ptosis, and
sensory loss along the ulnar aspect of his left
arm. He had moderate weakness of the intrinsic
muscles of his left hand.
Case 17
A 46 year old man has been experiencing neck
and shoulder pain radiating down his radial
forearm for the past month. It came on gradually,
and has slowly been getting worse. On physical
examination, strength was 5/5 throughout except
for right elbow flexion (4/5), right supination
(4+/5) and right wrist extension (4+/5). He
reported altered sensation along his right radial
forearm, thumb, and index finger. Biceps and
brachioradialis reflexes were 2+ in the left arm
and 1+ in the right arm. Otherwise, all reflexes
were 2+ and symmetric.
Case 18
A 34 year old woman was moving a refrigerator
into her first house when she felt a sudden “pop”
in her neck. She immediately developed soreness
in her neck which radiated down her left arm.
She presented to clinic a week later complaining
of the same symptoms. On examination, strength
was 5/5 throughout except for the left triceps and
finger extensor muscles, which were 4/5.
Sensation was mildly impaired to light touch and
pinprick over the posterolateral arm and into her
2nd, 3rd, and 4th digits. The right triceps reflex
was diminished.
Case 19
A 40 year old man was brought to the emergency
room by the paramedics after falling 40 feet off a
cherry picker and landing on his back. On arrival
he complained of extreme pain in his low back
and leg weakness. He had both bowel and
bladder incontinence. On exam, he had profound
weakness of his lower limbs. Hip flexion was
3/5, but he had no movement of the knee or
ankle. He was areflexic in the lower extremities
with downgoing toes bilaterally to plantar
stimulation. Plain films of his back demonstrated
a fracture dislocation in his mid-lumbar spine.
Case 20
A 58 year old tugboat captain with a long history
of chronic low back pain presented to clinic
complaining of new shooting pains in his leg. He
stated that the pain began in the low back and
radiated down the back of his left leg, across the
knee, and down to the top of the foot. On
examination, his shooting pains were reproduced
when his hip was flexed with the knee in the
extended position. He had mild weakness of left
foot dorsiflexion and toe extension. Ankle
inversion and eversion were also weak,
especially inversion. Patellar and Achilles
reflexes were 2+ and symmetric, and toes were
downgoing to plantar stimulation.
Case 21
A 66 year old man with along history of mild
low back pain reported that for the past 2
months, he had been experiencing debilitating
leg pain (left greater than right), that would only
occur after he had been standing for 10 minutes
or longer. The pain was located primarily in the
buttocks and upper legs, and would gradually get
better after sitting or resting for several minutes.
On physical examination, tone, bulk, and power
were normal in the lower extremities. Deep
tendon reflexes were 2+ and symmetric at the
knee and 1+ and symmetric at the ankles.
Ultrasound examination of the blood flow in his
legs was normal.
Case 22
A 51 year old female weaver seeing her primary
care physician mentioned that her hands had
been numb for the past two years. The numbness
was most prominent in her left thumb and was
exacerbated by working her loom. She also
complained about pain and paresthesias in her
hands and wrists that woke her up at night. On
examination, she had mild weakness of thumb
abduction. She had paresthesias and decreased
pinprick sensation, primarily over the left thumb
and index finger. Phalen’s test was positive (i.e.,
when she held her hands together with wrists
flexed, so that the dorsal aspects of both hands
touched, it reproduced her symptoms.) She had
no Tinnel’s sign (i.e. percussion of the median
nerve at the wrist produced no symptoms.)
Case 23
A 44 year old veteran, who worked as a
firefighter, came to clinic because of impaired
strength and dexterity in his right hand. He had
always been a very athletic man, but over the last
few months he could not lift free weights with
his right hand without dropping them.
Sometimes, he would get numbness between in
the fifth digit of his hand when he flexed his
right elbow. On physical examination, he had
marked atrophy of the interossei and the
hypothenar muscles in the right hand. Prominent
weakness of finger abduction was noted. He had
decreased pinprick sensation along the palmar
surface of the small finger and the ulnar half of
the ring finger. Reflexes were intact.
Case 24
A 55 year old woman came to urgent care clinic
and explained that she had awaked with right
arm weakness three days earlier. The night
before she had been drinking heavily, and she
fell asleep on her right side with the arm flexed
at the elbow. On physical examination, she had
2/5 strength in her right wrist and finger
extensors, and 3/5 strength in her right
brachioradialis. Elbow extension was 5/5.
Pinprick sensation was reduced over the right
first dorsal web space. Deep tendon reflexes
were trace and symmetric throughout the upper
and lower extremities.
Case 25
A 42 year old woman underwent an elective
breast reduction surgery. After waking from
general anesthesia, she noted weakness of the
right foot, and also numbness and tingling over
the dorsum of the right foot. She was discharged
with an appointment in the outpatient neurology
clinic. When she was seen there two months
later, there had been no significant change in her
symptoms. On examination, there was 4/5
weakness of ankle dorsiflexion and eversion.
Ankle inversion was 5/5. She had decreased
pinprick sensation over the dorsum of the right
foot. Reflexes were 2+ and symmetric
throughout.
Case 26
A 28 year old previously healthy man was half
way through his dental hygienist board exam
when he noticed that his left lip seemed to be
sagging and he had difficulty closing his left
eyelid. He finished the examination and drove
himself to the emergency room. On physical
examination, he had left facial weakness with
flattening of the nasolabial fold and partial
paralysis of eye closure. He was unable to
wrinkle his forehead on the left. Facial sensation
was normal and the rest of his neurologic
examination was unremarkable.
Case 27
A 55 year old man with hypertension and
diabetes presented with the sudden onset of
painless horizontal diplopia that was worse with
left gaze. On examination, there was esotropia in
primary position, worsened by left gaze. On
testing of ocular pursuit movements, the left eye
did not abduct fully, but other eye movements
were within normal limits. The remainder of the
cranial nerves were intact, and the rest of his
neurologic examination was unremarkable.
Case 28
A 34 year old woman with a history of
polycystic kidney disease presented with the
sudden onset of headache and oblique diplopia.
On physical examination, the patient had a
dilated, poorly reactive right pupil. The right eye
was deviated down and out, and had impaired
adduction, elevation, and depression. The left
eye moved normally. The remainder of the
neurologic examination was within normal
limits.
Case 29
A 51 year old ventriloquist came to clinic
reporting periodic “attacks” of facial pain for the
previous four months. He described momentary
bursts of severe, unilateral, “stabbing” pain in his
right cheek that came on spontaneously or with
certain stimuli, such as brushing his teeth or
shaving. Despite avoiding these activities, the
attacks had increased in frequency and at the
time of presentation were occurring almost daily.
Physical examination is normal.
Case 30
A 68 year old man with a history of
hyperlipidemia and smoking was brought in by
the paramedics after suffering from a single
generalized tonic clonic seizure that lasted about
2 minutes. By the time you saw him in the
emergency room, he was back to his baseline.
His wife then confided in you that he had been
acting “funny” for about a month. He had been
belligerent with family members and had been
neglecting basic hygiene. He had also been
incontinent of urine on more than one occasion
and did not seem to care. He has lost 30 pounds
since his last doctor’s appointment six months
ago. His exam was normal except for
papilledema in both eyes, pronator drift of the
left arm and a hacking cough.
Case 31
A 50 year old woman with no significant past
medical history presented with complaints of
episodic dizziness, tinnitus, and mild right-sided
hearing loss. These symptoms had become
progressively more frequent and more severe
since onset. The patient had a normal general
physical examination and no abnormalities on
neurologic examination other than the hearing
loss in her right ear. MRI showed a 1.5 cm
enhancing mass in the right cerebellopontine
angle, with a tail that entered the internal
auditory canal.
Case 32
A 60 year old man presented because of daily
headaches for about six weeks. He said that he
had been awakening every day with a headache,
and the need to vomit. About two weeks ago, he
had begun to have word-finding difficulties, as
well, and could no longer work as a cattle
auctioneer. On physical examination, he had
bilateral optic disc edema. He was able to name
4 out of 8 objects, and could not repeat the
phrase, “Shiver Me Timbers.” He had pronator
drift of the right arm. Neurologic examination
was otherwise normal.
Case 33
A 4 year old boy presented to clinic with four
weeks of headaches and three days of nausea and
unsteadiness. On physical examination, the
patient was awake but sleepy and irritable. He
had bilateral papilledema. He had significant
truncal ataxia and bilateral dysmetria.
Case 34
A 20 year old assembly line worker at a
Johnson’s Jigs and Fixtures presented with three
months of galactorrhea. She reported five years
of amenorrhea, with irregular menses before that,
starting at age 13. She reported occasional
headaches, but had no other symptoms. On
physical examination, she had bitemporal
hemianopia on confrontation testing of visual
fields.
Case 35
A 30-year-old woman was referred by her
internist because for the previous 3 weeks, her
left foot had a tendency to drag after the fourth
mile of her daily 5-mile run. Four years ago she
had a similar problem with her right foot, but had
attributed it to a twisted ankle, and the symptoms
had spontaneously resolved over the next month.
Her only other neurologic symptom had been a
partial loss of vision in her left eye eight months
ago. That had developed gradually over 4 days
and resolved over a few weeks; she had
attributed it to the stress of owning a new puppy
and starting a new job. Her examination was
normal except for a left afferent papillary defect
and mild hyperreflexia in her left lower
extremity.
Case 36
A 50-year-old right handed man woke with the
sensation of numbness and tingling over his legs
and trunk to the level of his nipples. He was able
to walk with some difficulty, stating he could not
feel his feet. The next day his legs began to feel
stiff and tight. Two days later he experienced
urinary retention. On physical exam his arms had
normal strength, sensation and reflexes. He had
decreased sensation below his nipples, increased
tone in his legs, and brisk lower extremity
reflexes. Plantar responses were extensor
bilaterally. Rectal tone was poor.
Case 37
A 42 year old female first developed leg
weakness and spasticity about 8 years ago. She
went from walking independently to being
wheelchair bound over the course of two years.
After that, she noticed that her right arm started
to become stiff and weak. At the time of
presentation, she was unable to feed herself, and
required intermittent urinary catheterization. She
complained of blurred vision, especially when
looking to the left, and “electric shock-like pain”
down her spine with neck flexion. She also
complained of profound fatigue, which is worse
during the hot summer months. On her physical
exam, she had impaired adduction of the right
eye. She was weak and spastic in all four
extremities, with hyperreflexia and upgoing toes
to plantar stimulation bilaterally.
Case 38
An 8-year-old girl was noted by her teacher to be
intermittently inattentive in the classroom. She
would stare with a blank expression on her face
for several seconds at a time. She would not
respond to her name being called and sometimes
had rapid fluttering movements of her eyelids.
Once the staring ceased, she would immediately
return to baseline. Her pediatrician was able to
provoke one of the spells by having the child
hyperventilate in the office. Physical
examination was normal.
Case 39
A 27-year-old man began to experience
stereotyped spells, that always started with an
unpleasant sensation in his abdomen. He would
then become unresponsive to those around him
and start staring and picking at his shirt buttons.
Next, he would fall to the floor and have
generalized stiffening of all four extremities
followed by shaking rhythmically for 30
seconds. He often bit his tongue during these
spells and was usually incontinent of urine.
Afterwards, he was confused for approximately 1
hour. The patient’s most recent spell was two
weeks ago. Physical examination today was
normal.
Case 40
A 34-year-old woman on phenytoin for a history
of complex partial seizure disorder was in her
usual state of good health when she was
witnessed to have a generalized tonic-clonic
seizure in the pet store one afternoon. When
EMS arrived, the patient had a second
generalized tonic-clonic seizure. EMS reported
generalized stiffening of all four extremities
followed by clonic movements, cyanosis,
frothing at the mouth, and urinary incontinence.
The patient has 1 more seizure without
recovering consciousness before reaching the
local emergency room.
Case 41
An 18-year-old college freshman with no
significant past medical history was brought to
the emergency department because of a
generalized seizure. He had completed exams on
Friday and had been drinking heavily over the
weekend to celebrate. His friend said that on
Saturday night he had passed out in a stairwell,
and shortly thereafter began to have generalized
shaking movements that lasted almost two
minutes, and he was confused for about a half an
hour afterward. The patient was back to baseline
at the time of presentation to the emergency
room and had no memory of the event. His
physical exam was normal.
Case 42
A 40 year old woman reported almost daily
spells ever since a month ago, a few days after
her husband shoved her roughly and told her that
he wanted a divorce. She described slowly losing
control of her legs and crumbling to the floor.
She denied loss of consciousness during these
spells, but reported that she was not able to speak
to people or follow commands during these
spells. Her mother, who had witnessed many of
these spells, stated that after falling to the
ground, her head would shake from side to side
and her pelvis would thrust wildly. She did not
experience any oral trauma or incontinence of
urine during the spells. The spells lasted
approximately 1 to 2 hours and only occurred
after dinner. Examination at the time of
presentation was normal.
Case 43
A 33 year old man with a known right frontal
astrocytoma experienced sudden uncontrolled
twitching of the fingers of his left hand. The
twitching progressed to include the entire hand,
followed by the arm and shoulder over the
course of one minute. It than subsided after
another minute. He remained conversant and was
fully conscious during the entire event.
Case 44
A 30-year-old woman came to the emergency
room because of severe headache for the
previous eleven hours. She first started having
headaches when she was in high school, but they
used to occur only about four times a year. In the
last year the frequency had increased, and the
patient now had headaches up to twice a week.
All of her headaches started on one side (usually
the right) and progressed to involve the entire
head. The headaches were associated with
photophobia, phonophobia, and nausea. Her
headaches would usually resolve within two
hours if she would lie down in a dark room and
take acetaminophen. Her current headache was
similar to her previous headaches, but had not
improved despite taking six acetaminophen pills.
Her examination was normal.
Case 45
A 26-year-old geophysics graduate student
reported occasional headaches since her
undergraduate years. They always started with
“squiggly lines” in her visual fields and
dizziness. These symptoms resolved in
approximately fifteen minutes and were followed
by debilitating pain behind her left eye which
radiated to her temple and occiput. She would
usually throw up when the pain became severe.
Lights and sounds bothered her, and she would
usually put a towel over her eyes and try to lie
still until the headache passed, which was
usually several hours or longer.
Case 46
A 56-year-old circus worker suffered from 4
weeks of explosive headaches. He stated that
they would come on very suddenly each day at
2:00am. The headaches were only on the right
side of his head, and were associated with tearing
of his right eye and right nasal congestion and
discharge. They typically lasted 45 minutes,
during which time he would go back to his trailer
and bang his head against the wall. He was
usually pain-free by 3:00 am and able to fall
back to sleep, but he then had trouble waking up
in time to feed the lions at 5:00am. He had
experienced the exact same thing several years
ago, and the episodes had abated after about two
months.
Case 47
A 19-year-old woman was evaluated by her
family doctor for a four week history of
headaches and a two week history of transient
blurry vision, nausea and vomiting. She had
started tetracycline for treatment of her acne
three months earlier. On physical exam
papilledema was present bilaterally. A contrast
MRI was normal.
Case 48
A 78-year-old woman presented with a 2 month
history of superficial head and face pain,
maximal over the left temple and suboccipital
region. She also noticed that after a few seconds
of chewing bubble gum, she would experience
jaw pain. The pain would resolve as soon as she
stopped chewing. Blowing bubbles did not
exacerbate the pain. On examination, her scalp
was tender to the touch over the left temple.
Case 49
A 33 year-old female with newly diagnosed
hypertension presented to the emergency room
several hours after suddenly experiencing a
severe headache, photophobia, stiff neck, and
nausea. She denied concurrent illnesses.
Temperature was 98.0 degrees. Blood pressure in
the emergency department was 220/110. She
became obtunded in the emergency room, and
within an hour she no longer followed
commands or produced any spontaneous speech.
On cranial nerve exam her left pupil was dilated
and poorly reactive to light.
Case 50
A 55 year old woman presented with ongoing
headaches, occurring once or twice a week. She
described a vice-like squeezing pressure across
her forehead and the back of her neck. She was
in the process of moving to a new house, and the
stress associated with the move seemed to make
her headaches worse. She was otherwise in good
health, and denied nausea, vision changes,
numbness or tingling, neck stiffness, or fevers.
Case 51
A 46 year-old man was brought to the
emergency room by his brother for evaluation of
headaches and fever. He had been sick for a
couple days with a “sinus infection,” but on the
day of presentation, he developed a severe
headache. In the emergency room his
temperature was 104 degrees F. He appeared to
be very uncomfortable. His neck was stiff and
very sensitive to passive manipulation. A head
CT without contrast was performed and was
normal. A lumbar puncture was performed, and
the opening pressure was elevated. The CSF
studies were as follows: WBC 1550 with 80%
segmented neutrophils, RBC 10, Glucose 30,
Protein 57.
Case 52
A 50-year-old retired autoworker was brought to
the emergency room by her husband for
evaluation of the worst headache of her life. That
morning she had developed a severe bifrontal
headache with neck stiffness and light
sensitivity. She had vomited twice in the car en
route to the hospital. On exam she was febrile to
101 degrees F and in mild distress. Her neck was
stiff and very sensitive to passive manipulation.
Her discs were flat on funduscopic exam, and the
remainder of her neurologic exam was normal.
Head CT showed no bleed. A lumbar puncture
was performed, and the opening pressure was
within normal limits. CSF studies were normal
except for a WBC of 8 with lymphocytic
predominance.
Case 53
A 52 year old homeless woman with diabetes
was found unresponsive in an off-duty bus. On
exam, temperature was 104 degrees F. She had
poor dentition with carious teeth and exudative
lesions in her gums. She did not respond to
visual or auditory stimuli; to painful stimuli
she would moan and withdraw her left leg, but
not her right. Funduscopic exam revealed mild
papilledema on the left. Plantar response was
extensor on the right. During the examination,
the patient had a 30 second generalized tonic
clonic seizure.
Case 54
A 38 year old woman had a fifteen minute period
of hypotension during a mitral valve repair
surgery. After the surgery, the patient was
“unresponsive,” so neurology was consulted. On
physical examination, the patient’s eyes were
open and pupils were responsive to light.
Respirations were intact. She did not speak and
did not respond to voice. She did not track
objects but did appear to look randomly around
the room. The medical staff noted that she had
sleep-wake cycles. Motor tone was flaccid.
Case 55
A 20 year old was using a chainsaw to cut high
branches near his house when he cut through a
high voltage power line. He fell from the ladder
and was immediately unresponsive. The
paramedics were called to the scene and found
the patient in asystole. He was intubated and
cardioverted back to normal sinus rhythm after
being down for approximately 20 minutes. When
he arrived in the emergency room, he was
unresponsive to all stimuli, including sternal rub.
He took no spontaneous breaths. His pupils were
fixed and dilated in mid-position. His
oculocephalic and vestibulo-ocular reflexes were
absent. Gag and corneal reflexes were also
absent. Deep tendon reflexes were intact. Head
CT and basic laboratory studies were all within
normal limits. The next day, his exam was
unchanged.
Case 56
A 49 year old man came to clinic because of
excessive daytime somnolence for approximately
six months. He reported that he slept at least
seven hours a night, but in the mornings he felt
“unrefreshed and headachey.” His wife
accompanied him today, and started that she had
started sleeping in a different room because he
was a loud snorer. She also noted that he often
“stopped breathing” for several seconds at a time
during his sleep. On physical examination, the
patient was overweight (242 pounds) with no
focal neurologic deficits.
Case 57
A 29 year old man reported that he had been
“falling down” frequently over the last five
years. He said that when he heard a funny joke or
got angry about something, he would gradually
collapse to the ground. He reported excessive
sleepiness and the need for frequent naps during
the day. He also reported vivid hallucinations
while falling asleep. He also described some
terrifying episodes that occurred after a nap, in
which he was unable to move or speak for
seconds to minutes, even though he felt wide
awake. His physical examination was within
normal limits.
Case 58
A 60 year old man was brought to clinic by his
wife, who claimed that he had been “acting out
his dreams” for several years. Sometimes he
would scream and kick, or even fall out of bed
and start flailing his arms violently. One time, he
actually punched her repeatedly while he was
sleeping. If she tried to wake him up, he would
awake immediately, and describe a dream that
correlated with his actions. Physical examination
was within normal limits.
Case 59
An 80 year old woman with a history of chronic
obstructive pulmonary disease (COPD), diabetes
mellitus, and chronic low back pain was brought
in from the nursing facility where she lived
because of mental status changes. Her caregivers
stated that at baseline, she was alert, conversant,
and largely independent. However, on the
morning of presentation, she was found to be
confused and irritable, and “She kept saying the
F-word.” On examination, her temperature was
99.0, her blood pressure was 94/50, and her
oxygen saturation was 92% on room air. She had
waxing and waning alertness, and was not
oriented to place or time. She was sleepy, and
very uncooperative with the exam. Cranial
nerves were intact and she was moving all four
extremities equally. Her reflexes were
symmetric, but when you tried to test them, she
said the F-word. Examination was otherwise
normal.
Case 60
A 77 year old woman was brought to clinic by
her family because of “short-term memory loss.”
Her son noted that the patient began having
problems with her memory about three years
ago. Specifically, she was misplacing things,
forgetting the names of acquaintances, and
having difficulty managing her own finances.
Over the last year, she began getting lost while
driving, confusing the names of her own
children, and wearing dirty clothing. On
cognitive examination, she was oriented to the
year but not the date or month. She knew she
was in a doctor’s office but did not know what
town it was in. She could not recount any recent
major news events. She was able to name a
finger and a watch, but not a thigh or a lapel. She
was able to draw a clock, but could not draw the
hands to indicate 10:15. She could repeat three
words, but could not recall any of them after five
minutes. General neurologic examination was
normal.
Case 61
A 50 year old man was brought to clinic by his
family who felt he was depressed. Over the last
two years, he had become socially withdrawn.
He had made inappropriate comments to his
family, including comments of a sexual nature to
strangers. He had locked his dog in the basement
without food for three days because “it was
getting fat.” Over the last six months, his family
had noted progressive cognitive decline, as well.
The decision to seek medical attention was
prompted by an episode two months ago when
he was arrested for taking his clothes off in a
Taco Bell. On cognitive testing, he had profound
difficulty with naming and abstract reasoning,
and mild memory impairment. General
neurologic examination was otherwise normal.
Case 62
A 70 year old man presented to clinic with three
years of progressive cognitive decline. His wife
tells you, “Some days he seem fine and other
days his thinking is way off.” She reported that
some days, he had hallucinations of children
walking around the house, or cows grazing in
their yard. Over the last six months, he had
begun to move more slowly. On cognitive
examination, he had mildly impaired orientation
and verbal recall. He was completely unable to
draw interlocking pentagons or mimic sequential
hand gestures. On general neurologic
examination, he had a somewhat masked face.
He had mild cogwheel rigidity in both upper
extremities. He performed fine finger
movements slowly and clumsily. No tremor was
present. He had a slow, shuffling gait.
Case 63
A 70 year old man with a history of hypertension
presented to clinic with two years of progressive
memory and balance problems, as well as recent
onset of urinary incontinence. On cognitive
examination, the patient had impaired memory,
was unable to perform simple calculations, and
could not draw interlocking pentagons.
Language was normal. On general neurologic
examination, the patient had a slow, wide-based
gait.
Case 64
A 12 year old boy presented to clinic with a two
year history of abnormal behaviors. His mother
said that the first thing that she noticed was
episodic blinking and eye rolling. After a few
months, this gradually subsided but was replaced
with episodes of twitchy shoulder shrugging. A
few months later he developed episodes of
grunting, tongue clicking or humming. The
patient stated that he had a very strong desire to
perform each tic, but could overcome that desire
for a short period of time if he tried. On
examination, the patient had multiple episodes of
eye-blinking during the examination, and
occasional grunting. The remainder of his exam
was normal.
Case 65
A 16 month-old girl was referred by her
pediatrician for evaluation of leg weakness and
hand tremors. She was the product of normal
pregnancy and uncomplicated vaginal birth. The
patient was crawling by 9 months and since
about 12 months she was able to walk holding
onto furniture. However, she never developed
the ability to walk independently. On neurologic
examination, cognition was normal for age. She
had decreased tone and strength in all four
extremities, most prominently in the lower
extremities. There were no sensory
abnormalities. Reflexes were completely absent
throughout.
Case 66
An 8 year old boy was brought to the
pediatrician because of a “lazy left eye” over the
past six weeks. Other than a mild learning
disability, he had no significant past medical
history. On examination, he had decreased visual
acuity in the left eye (20/200) with a left relative
afferent pupillary defect, temporal visual field
deficits, and a pale optic disc. Small hematomas
and nodular clumps of pigment were noted in
both irises. His general examination was
significant for axillary freckling and
approximately ten café au lait spots on his back,
chest, and extremities. An MRI of the patient’s
brain showed an enhancing-mass on the
proximal portion of the left optic nerve.
Case 67
A 6 year old girl presented to clinic with lifelong
stiffness and weakness in both legs. She had
been born five weeks prematurely via breech
delivery. She was delayed in all major motor and
cognitive milestones, but had not regressed in
any way. On physical examination, the patient
had profound spasticity in both legs, with clonus
at both the knees and ankles and upgoing toes to
plantar stimulation.
Case 68
A 7 year old boy was brought to clinic with new
onset seizures. His parents noted that for the last
two years he had a short attention span and
difficulty following instructions. Over the last
year, his speech had become progressively
slurred, and he had intermittent urinary and
bowel incontinence. His cognition had also
declined. He had a past history of intermittent
vomiting and dehydration since he was two years
old, and his skin had been excessively tan since
he was four years old. On physical examination,
he had poor visual acuity and a spastic
dysarthria. Strength was within normal limits,
but the patient’s reflexes were diffusely brisk,
and he had upgoing toes bilaterally.
Case 69
A 6 month old boy was brought to the
emergency room by his mother, who reported
that he fell out of his crib onto his head the night
before, and had been “acting weird” since then.
He had been feeding poorly and vomited several
times. On general exam, the baby has bruises on
his head, shoulders, and neck. He was lethargic
and irritable. His head size was increased and his
fontanel was tense. Retinal hemorrhages were
noted bilaterally on funduscopic examination.
Case 70
A 71-year-old man complained of “shakiness”
in his left hand beginning 8 months ago. He
was otherwise in good health and taking no
medications. He provided a clear, concise
history. On exam his face was expressionless
and he blinked infrequently, although his facial
muscles activated symmetrically. He had a
prominent resting tremor of his left arm that
improved with volitional movement. There was
some cogwheel rigidity on the left and
impaired rapid movements of the left hand. He
had a stooped posture and took small shuffling
steps. Arm-swing was decreased on the left,
and the patient took six steps to turn around.
Case 71
A 50 year old woman presented to clinic
complaining of tremor in her hands. The tremor
had been present for about three years, and had
gotten worse over the last six months. It was
present equally in both hands and she noticed it
most when trying to hold a magazine or a cup of
coffee. It was worse with stress and better with
alcohol. Therefore, she frequently drank 2-3
ounces of vodka before having dinner with her
in-laws. On physical examination, the patient
had a high amplitude 6-Hz postural and kinetic
tremor that extinguished with rest. Muscle tone,
limb coordination, posture and gait were all
normal.
Case 72
A 28 year old woman with a ten year history of
bipolar disorder was referred to neurology clinic
by her primary care doctor for evaluation of
“tics.” The patient’s husband reported wildly
fluctuating mood changes and progressively
impaired cognition over the last five years. On
examination, she had mild dysarthria.
Involuntary distal twitching and dancing
movements of her hands and toes were noted.
Her gait was broad-based and she was unable to
walk in tandem.
Case 73
A 15 year-old girl presented to the clinic with six
months of progressive cognitive decline,
irritability and tremor. On examination she had
hypersalivation and diminished facial
expression. Irregular regions of muddy brown
discoloration were present on her corneas. She
had a wing-beating tremor and impaired
handwriting.
Case 74
A 41 year-old woman presented with a ten year
history of involuntary head rotation to the right.
It was present at all times, but exacerbated
periodically by a sharp jerking movement to the
right. The involuntary movements were
exacerbated by anxiety. She was on no
medications. Other than the episodes that she
described, her physical examination was normal.
Case 75
A 60-year-old man with no past medical history
stated that his speech had become progressively
more unintelligible over the last year. Recently,
he began having problems with “food going
down the wrong tube.” He also noticed that he
was having difficulty with walking and his hands
and feet were getting tired more easily. On
physical exam, fasciculations were noted in his
tongue, trapezius, and quadriceps muscles. He
had atrophy in the intrinsic muscles of his left
hand and right foot and weakness in these areas.
Reflexes were 3+ diffusely, with an upgoing toe
on the left to plantar stimulation. Sensory exam
was normal.
Case 76
A 58 year old boiler inspector from Gary,
Indiana presented to clinic for evaluation of
numbness and pain in his feet. The symptoms
started approximately five years ago in his toes,
and gradually spread to involve both feet. He
described the pain as burning in nature, and more
bothersome at night. He said he was in perfect
health and had not seen a doctor since his army
physical at age 20. On physical examination, he
had decreased pinprick sensation below midshin
and absent vibration and position sense below
the ankle. Upper extremity reflexes were 2+,
patellar reflexes were 1+, and ankle jerks were
absent. The patient’s gait was mildly wide-based
and Romberg sign was positive.
Case 77
A 30-year-old man presented to the emergency
room with lower extremity tingling and difficulty
walking. He developed back pain and toe
tingling three days prior, and the other symptoms
had progressed since then. On examination, he
had mild bilateral facial weakness and weakness
of all four extremities distally, with relative
sparing of the proximal muscles. Sensation was
intact, but the patient reported “abnormal
sensations” distally in all four limbs. Reflexes
were absent throughout.
Case 78
A 40 year old man presented because of
progressive leg weakness. He stated that he had
always had high-arched feet, and as a child, he
was always the slowest runner and could not ice
skate. When he was a teenager, he began to have
more problems with his feet and his ankles
would sometimes give out on him for no reason.
During the last two years, he noticed progressive
numbness in his feet. He had been tested for
diabetes, but did not have it. On examination, he
had wasting of the intrinsic hand muscles and
calves with a pes cavus deformity. Strength was
full proximally, but 4/5 in the intrinsic muscles
of the hands and feet. Temperature and pinprick
sensation were diminished to mid-calf and the
wrist. He was areflexic. Romberg sign was
positive.
Case 79
A 34 year-old woman came to her physician
because of fluctuating double vision. She stated
that when she woke up in the morning, she felt
fine, but as the day wore on, she would develop
horizontal diplopia. She also reported episodic
slurred speech and swallowing difficulties. On
physical examination, she developed bilateral
ptosis after trying to sustain upgaze for 30
second. Examination was otherwise normal.
Case 80
A 4-year-old boy was brought to his pediatrician
because of gait abnormality. He was the product
of an uncomplicated birth and delivery. He did
not walk until 18 months of age, and when he
did start walking, he would walk on his tiptoes
and waddle. His parents reported that he fell
frequently and had difficulty getting up. On
physical examination, he had large calves. He
was weak in the deltoids, biceps, and hip girdle
muscles, but relatively strong distal muscles.
Case 81
A 50 year old man reported weakness and
fatigue for the past 2-3 months. He was having
progressively more difficulty with certain tasks
such as combing his hair, lifting his brief case, or
climbing stairs. He initially denied talking or
swallowing problems, but eventually admitted
that he choked a few times when trying to eat
steak too fast. He had no problems with fine
motor activities, such as buttoning his shirt or
writing. On physical examination, the patient had
4/5 strength in neck extension, as well as the
proximal muscles of his upper and lower
extremities symmetrically. Sensation and
reflexes were normal.