Case histories: Answers

Published on 09/04/2015 by admin

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Last modified 09/04/2015

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Case histories

Answers

Case 1: Carpal tunnel syndrome (p. 106)

The history of numbness in the hands waking the patient from sleep is classical for carpal tunnel syndrome. As the median nerve compression progresses, the symptoms intrude into the day and a fixed deficit in median nerve distribution may emerge. Nerve conduction studies usually confirm the diagnosis and treatment is with decompression at the wrist.

Case 2: Acute bacterial meningitis (p. 98)

The fever points to infection and the neck stiffness suggest meningitis. The time course is typical for acute bacterial meningitis, which may be complicated by seizures. Seizures are commoner in encephalitis but the evolution is usually slightly slower in onset and there is less neck stiffness. He should be treated with antibiotics prior to having a scan and lumbar puncture.

Case 3: Myasthenia gravis (p. 110)

The variability in the history, fatiguability and a pattern of diplopia not fitting with any specific cranial nerve make the diagnosis highly likely to be myasthenia gravis. Diagnostic tests are acetylcholine receptor antibodies, neurophysiology and edrophonium test. Treatment is with pyridostigmine and immunosuppression.

Case 4: Juvenile myoclonic epilepsy (p. 74)

The history of myoclonic jerks for many years before a tonic-clonic seizure is typical and many patients also have absences. This form of epilepsy is often made worse by carbamazepine and the most effective treatment is usually sodium valproate.

Case 5: Benign paroxysmal positional vertigo (BPPV) (p. 47)

This is the typical history for BPPV and the manoeuvre described is Hallpike’s test, which confirms the diagnosis. Treatment is the Epley’s manoeuvre.

Case 6: Subdural haematoma (SDH) (pp. 67 and 78)

The history and signs point to a progressive left hemisphere lesion. With a head injury preceding the onset, the first diagnosis is SDH. These are commoner in patients on warfarin or aspirin. Alternative diagnosis is a tumour unrelated to the injury.

Case 7: Cervical cord compression (p. 80–83)

He has lower limb spasticity due to bilateral upper motor neurone dysfunction pointing to a spinal lesion. The highest abnormal sign is the absent biceps reflexes, implying a lower motor neurone abnormality at the level of the biceps motor roots and therefore a motor level at C6. Worsening with cough suggests the cause is compressive; spondylosis or tumour. He should have emergency MRI of the cervical spine and neurosurgical referral.

Case 8: Guillain–Barré syndrome (GBS) (p. 104)

The patient has generalized weakness and loss of reflexes pointing to a diffuse lower motor neurone disturbance and the patient has a sensory disturbance consistent with a neuropathy. The subacute course and preceding infection are typical of GBS. Nerve conduction abnormalities and elevated protein level in the cerebrospinal fluid are common but may take time to develop; treatment is with IV immunoglobulin or plasmaphoresis on the basis of the clinical picture.

Case 9: Migraine and analgesic misuse headache (p. 43)

The earlier history of discrete headaches is typical of migraine. This has changed to a more continuous headache only partially treated by analgesia, typical of analgesic misuse headaches. Common culprits are codeine, caffeine, paracetamol and triptans. No investigation required. Treatment is to withdraw analgesia and consider migraine prophylaxis.

Case 10: Syncope (p. 44

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