1. Clinical reasoning By Dr. Walid I. Wadi Jan,5 th 2010

2. A 28 year old female patient presents with 2 week history of unsteady gait with tendency to fall to the left. She reports that she has recently noted heaviness in here left lower limb. She gives history of paresthesia in the right arm and occasional diplopia. She gives history of electric like feeling in her back and limbs upon looking downwards. She denied any history of headache or back pain. She had no history of fever.

3. Past history: She gave history of similar symptoms 8 months earlier that resolved over 1 month with treatment. Family history No similar events in the family ROS : Normal apart from occasional urgency.

4. What other points in the history has to be inquired about at this stage?

5. On examination Well, a febrile Systemic examination was unremarkable Neurological exam: Conscious, oriented Failure of the lateral gaze of the right eye Pupils equal and reactive Pale optic discs bilaterally

6. Left lower limb was spastic with 4/5 power. Reflexes were brisk with extensor planters, and positive ankle clonus. Heel-shin test was abnormal on the right lower limb. Touch and pin prick sensations over the right upper limb were reduced ( not limited to dermatome)

7. What parts of the nervous system are involved in this patient? Can you localize the lesion? Give 4 important differential diagnoses? How would you investigate this patient? Outline the important lines of management/ prognosis?

8. Case 2

9. A 35 year old male was brought by his family unconscious? They state that he was sad lately and was not going to his work or caring about his family. His wife states that he has diabetes mellitus for 5 years on insulin on irregular follow up.

10. On examination His was unresponsive to verbal or painful stimuli and was not opening eyes spontaneously. Pulse 70/min. Temp. 38.1 C BP 95/64 Resp.rate 20/min

11. General examination showed bad dental hygiene. Multiple bruises were noted over both forearms. Chest exam: crackles over the right base

12. Pupils were constricted bilaterally. Meningeal irritation sign were negative No focal neurological sign was detected. Reflexes were depressed symmetrically in both upper and lower limbs.

13. Issues for discussion Outline the important differential diagnoses? How can you differentiate metabolic from neurological coma? What is the possible cause for his chest findings?

14. What are the important investigations needed to reach the possible diagnosis/es? How would you approach this patient in the emergency room?