Published on 10/04/2015 by admin
Filed under Neurology
Last modified 10/04/2015
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Case histories
Neurology cannot really be learnt from a book. Once you have the tools to make sense of neurological presentations and a framework of understanding of the range of neurological conditions, you are in the position to learn neurology from clinical practice – patient by patient as you help solve their clinical problems.
To get you on your way, here are some clinical cases, with examples of many common or important neurological conditions. The questions for all are the same – reflecting clinical practice rather than any kind of exam practice – ‘what is your diagnosis?’ and ‘what would you do next?’ Some are accompanied by results of investigations, which, as in real life, may not be relevant. Brief answers are given on pages 127–128 with references to the relevant section of the book.
A 48-year-old woman complains of numbness in both hands. She first noticed this 18 months ago, but initially it was intermittent and most often at night or when she was driving. For the last 3 months it has been continuous and she has had trouble with fine movements – such as doing buttons up.
Examination is normal apart from mild weakness of abductor pollicis brevis in both hands and a subjective alteration to pinprick in the thumb, index and middle fingers.
A 35-year-old man is brought to Accident and Emergency with a headache that has become increasingly severe over the preceding 6 h. The paramedics reported he had had a seizure in the ambulance. He is febrile and unwell. He has a stiff neck and is confused with no focal neurological signs.
A 24-year-old woman has a 6-week history of intermittent double vision. She notices images can be displaced either side by side or on top of one another. She has otherwise felt well.
On examination she has a mild right-sided ptosis which fatigues, and a variable double vision looking up with vertically displaced images, with the outer image in the right eye. The remainder of the examination is normal.
You are asked to see an 18-year-old man urgently. He had two generalized seizures without any warning 2 months ago, attended hospital and was started on carbamazepine. Since then he has had increasingly frequent generalized seizures despite increasing doses of carbamazepine. He tells you that he has also had some blank spells, when he has missed some time. You ask him if he has any sudden jerks of his limbs, and he says he has and has had for many years, though recently he has been getting many more.
Examination is normal apart from the bite mark on the side of his tongue from a seizure he had earlier in the day.
A 68-year-old woman complains of dizziness. She has had episodes of feeling dizzy, with a sensation of rotation lasting a minute or so, which then leaves her feeling wobbly for 10–15 min. She finds it occurs on looking up or rolling over in bed.
Conventional neurological examination is normal. On getting her to lie back flat with her head to the right, you notice torsional vertigo to the right which comes on after 5 s, and lasts about 10 s, when she tells you she feels dizzy, before fading.
A 68-year-old man presented with a 4-week history of progressive right-sided weakness. His family had noticed that this had been associated with some problems with his speech, as he sometimes seemed to find it difficult to find the right words, and a general slowness in thinking. He had been in a minor road traffic accident 2 months ago. He had been put on aspirin 3 years ago for mild angina.
On examination his speech was non-fluent and he had a mild right hemiparesis with brisker reflexes on the right and an extensor right plantar response. Sensory examination was normal.
A 54-year-old man presented with a 4-day history of difficulty walking. He had been decorating 5 days before when he developed a pain between his shoulder blades with some numbness in his little fingers. Since then he had increasing numbness in his hands and gradually deteriorating walking with increasing leg weakness. He had developed urinary urgency. When he coughed he felt his symptoms were worse.
On examination his cranial nerves were normal. He had mild weakness of finger extension and elbow extension with moderate weakness affecting both legs, particularly hip flexion, knee flexion and foot dorsiflexion. Tone was increased in his legs. The biceps reflexes were absent, with reflex spread to finger flexion. Knee and ankle reflexes were brisk with bilaterally extensor plantars. Vibration sense was lost to the sternum, proprioception impaired at the toes, with a level to pinprick at T4 on the chest with loss on the medial forearm and hand to the middle finger.
Neurology An Illustrated Colour Text
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