Case histories

Published on 10/04/2015 by admin

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Case histories

Cases

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.

Case 1

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.

Case 2

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.

Case 3

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.

Case 4

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.

Case 5

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.

Case 6

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.

Case 7

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.

Case 8

A 33-year-old man presents with a 3-day progressive history of weakness and sensory loss. He had just got over a cold when he began to get numbness in both feet which spread up his legs and to his hands and arms over the next few days, with an increasing heaviness and weakness. He had not been able to get out of bed this morning because of weakness.

On examination he was afebrile. Cranial nerves were normal. He had generalized weakness with all arm muscles grade 4 and legs 3. He was areflexic. Plantars were unresponsive. Vibration sense was lost to the anterior superior iliac spines, proprioception was normal and there was pinprick and temperature loss to the knees.

Case 9

A 44-year-old woman presents complaining of headaches. These had begun 3 years ago with a pain around the top of her head. This was constant, though on some days the pain became more severe. She was taking cocodamol, 2 tablets 4 times a day, which helped a little. Previously she had more discrete headaches that lasted 6–8 h and were preceded by flashing lights, which occurred perhaps once a month, though she had not had one for maybe 18 months.

Neurological examination was normal, with normal retinal venous pulsation on fundoscopy.

Case 10

An 18-year-old girl is referred after she had a blackout in a nightclub. She recalls being in the nightclub and feeling unwell and sweaty. She made her way to the exit and got outside. She next recalls coming to on the floor with her friends around her, but knew exactly where she was. She had been incontinent. She tried to get up but briefly blacked out again.

Her friends report that she said she felt awful as she went outside. She then fell to the ground where she twitched slightly for about 20 s before coming to and making good sense. They tried to sit her up and she went out again for a few seconds. It was too dark to see her colour. She had never had any other episodes and examination was normal.

Case 11

A 68-year-old man reports that the day before presentation he had lost the use of his right arm and speech for about 10 min. It had come on suddenly and gradually improved. He otherwise had felt well. He had never had similar problems before. He had mild hypertension, for which he took atenolol, but was otherwise well.

Neurological examination was normal. He was in sinus rhythm, BP 155/90, normal cardiac examination with no carotid bruits.

Case 12

A 55-year-old man presents with an increasing weakness in his right hand. This has come on gradually over the last 6–8 months, particularly interfering with using the key in the door and writing. He feels his grip is weaker. He has noted some numbness in his little finger. He is otherwise well.

On examination he has wasting of the right first dorsal interosseous with weakness in that muscle and in the right abductor digiti minimi and the long flexors of the little and ring fingers. Other muscles are normal. Reflexes are normal. There is a loss of pinprick sensation over the little finger and the medial half of the ring finger on the right.

Case 13

A 33-year-old woman presents with a 1-week history of dizziness and 3-day history of double vision. She had noticed her left side felt clumsy over the last couple of days. She recalls having an episode when she lost vision in her right eye for a few weeks 5 years ago.

On examination she has an impairment of left eye adduction with normal right eye abduction on looking to the right, with some nystagmus in the right eye. She has a pale right optic disc with normal acuity and field. Power in her limbs is normal with normal reflexes. Sensation is normal. Her gait is ataxic and she has ataxia in the left arm and leg.

Case 14

A 75-year-old man reports a 12-month history of increasing difficulty using his left hand. He had noted he had more difficulty doing up buttons. He had noticed that his automatic winding watch had stopped winding, which he realized was because his arm had stopped swinging when he walked. His left shoulder felt stiff.

On examination he was well. His facial expression was normal, as was examination of his cranial nerves. His gait was slightly stooped and his left arm was slightly flexed and did not swing. Tone was increased in his left arm with cogwheeling. Power was full with symmetrical reflexes. There was mild slowing in fast repeating movements in his left hand and slightly in his left foot. Sensation was normal.

Case 15

A 68-year-old woman reported a 6-month history of increasing difficulty with her speech, which was becoming progressively slurred, and 1 month of difficulty swallowing. She had some cramps in her hands and thighs. She had lost a little weight, though was not sure how much.

On examination she was thin. Examination of the eyes and eye movements were normal. Her speech was slow and slurred. Her tongue was wasted and fasciculating; tongue movements were very slow. There were fasciculations in all muscles in the shoulder girdle and in both quadriceps; however, power in both arms and legs was normal. All her tendon reflexes were brisk with bilaterally upgoing plantars. Sensory examination was normal.

Case 16

A 37-year-old man presents to Accident and Emergency with a headache. This had come on suddenly 12 h before while he was jogging. He had to stop and sit down and then called his wife to take him home. He had been in bed since and vomited once. The headache was persisting. He had occasional mild headaches in the past but nothing like this.

Neurological examination was normal but his neck was a little stiff. A CT brain scan was reported as normal.

Case 17

A 48-year-old man presents with a history of progressive difficulty walking over the last 4 months. He has noticed his right leg is stiff and there is slight clumsiness of his right hand. His wife comments he sometimes seems to mix his words up and say the wrong word. On three occasions in the last 2 weeks his right leg has jerked repeatedly for about 5 min and then has felt even weaker, so he cannot walk for a further half hour.

On examination there is a supinator catch in the right arm and increased tone in the right leg. Reflexes are increased in the right leg with an extensor plantar response. Sensation is normal. He circumducts his right leg slightly as he walks and the ankle is slightly plantarflexed.

Case 18

A 38-year-old woman presents with sudden onset of weakness, nausea and double vision. She tells you that 10 days ago she injured her neck playing squash and that for the last 5 days she has had pain in the left side of her neck.

On examination the left pupil is smaller than the right and there is a partial left ptosis. The left eye fails to abduct on looking to the right, though other eye movements are normal. The right arm and leg are slightly weak with reduced sensation to pinprick. There is finger–nose incoordination of the left arm and heel–shin incoordination of the left leg. Reflexes are brisk on the right with an extensor plantar response. She is unable to walk.

Case 19

A 57-year-old man presents with a sudden onset of mild left-sided weakness with no other symptoms. He has a history of rheumatic fever in childhood but no other medical problems.

On examination he is in atrial fibrillation and is normotensive. His neurological examination reveals slight drooping of the left side of his mouth. His left arm and leg are slightly weak with increased tone and brisk reflexes. The plantar response is uncertain.

Case 20

A 65-year-old man is brought to you by his wife who says he is becoming forgetful. He retired from work 4 years ago because he was starting to make mistakes and his memory has declined since then. He remembers the names of only three of his five grandchildren. His wife says at times he has become more aggressive and different from his usual self and has accused her of stealing things from him. He recently got lost when they were out shopping together in town.

His physical examination is normal but he remembers only one of three objects at 1 min and fails to draw intersecting pentagons. He cannot remember the date or month. He scores 23/30 on Mini-Mental State examination.

Case 21

A 58-year-old woman is referred from the medical wards. Her family describe an illness starting 3 months earlier with memory disturbance and she has deteriorated rapidly. Six weeks ago her walking started to become unsteady and they brought her to hospital; tests including her CT brain scan and general blood tests are normal.

On examination you find that there are asynchronous spontaneous jerks of her limbs, which seem to be triggered by loud noises. She has difficulty cooperating with the examination and seems drowsy. She does not speak and her family tell you they are not sure if she recognizes them. A full examination is difficult but there are no obvious cranial nerve signs, no wasting and tone is normal. Reflexes are brisk but with flexor plantar responses.

Case 22

A 73-year-old woman complains of headache of 3 weeks’ duration. The pain is made worse by chewing and she has found that her scalp is tender when she combs her hair. She has been off colour and lost 2 kg in the same period.

Her neurological examination is normal.

Case 23

A 28-year-old woman presents with stereotyped sensations that have been occurring for 1 year. They tend to cluster in the week before her period. She feels a strange feeling rising from her stomach and a sensation that everything is very familiar. On one occasion the feeling was so intense that she had to pull over for 3 min before she could continue driving home. Her husband has seen one event and said she looked pale, appeared to be chewing something and did not answer him during the attack. She took a few minutes to recover and had no recollection of the episode.

She was previously well and her examination is normal.

Case 24

A 33-year-old man presents with headache for 4 weeks and a right-sided lower motor neurone facial weakness for 3 days. He has had night sweats for the last 2 weeks and has lost 5 kg in weight. On the day of admission he had developed deafness in his left ear.

He is mildly confused and has a temperature of 37.7°C. His neck is slightly stiff but there are no other signs. His CT scan shows mild ventricular dilatation.

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