Vignettes Session 6 new R. Wiley, MD, PhD

79 y/o RH WF presents to ED with left sided twitching. Two months ago, she began to notice that her left leg would twitch w/ episodes lasting 1-3 min. One month ago, her left arm would twitch also and she has also noted progressive weakness of the left side of her body. Today, her left hand became almost completely limp. She has been losing weight despite good appetite, and she has developed a cough. PMHx and FamHx: negative Meds: vitamins Vitals: P 80 BP 110/70 R 20 T 37 General: cachexia, decreased breath sounds bilaterally, dullness at L lung base Neurological: intact except – Sensory – decreased proprioception on L hand Motor – flaccid L hemiparesis Reflexes – extensor plantar on L

52 y/o M w/ 8-year history of colon cancer on chemo until 6 months ago is admitted for confusion and lethargy. For past 2 months, he has had poor appetite and intermittent vomiting. Two weeks ago, he had 2 generalized seizures, and was started on phenytoin. Since then, he has become progressively more confused without recurrent seizure. FamHx and SocHx are not contributory except pt does admit to drinking Etoh but can’t exactly quantify. Vitals: P 100 BP 110/70 R 20 T 37 General: skin and sclerae icteric, nodular liver palpable 3 cm below costal margin Neurological: MS – oriented to self, recalls 0/3 at 5 min, present President “that blond woman, I can’t remember her name”, slow but accurate calculation Gait – refused as he becomes lightheaded Coord – mild intention tremor on FNF CN – intact except - nystagmus in direction of horizontal gaze Sensory – decreased vibration, pain and light touch in stocking distribution Reflexes – trace in UE, absent in LE

47 y/o RH WF with 2d Hx of word finding problems and memory as well as concentration difficulty. She reports a 1.5yr of BLE numbness and gait unsteadiness, worse in the dark. These sx were of gradual onset. For the last 6mo she has needed to use a walker to get around. She also has shooting pains in her neck and back and both arms. FH is negative. Meds: She has only used occasional NSAIDs for back pain. Soc Hx: She smokes 1/2ppd, no drugs and social etoh. She was single and worked as a security dispatcher. General: T-98.2, HR-68, B/P-110/60, R-18, P/E - unremarkable Neurological: MS - alert, oriented, fluent, conversant, 26/30 on MMSE missed 2/3 on recall and couldn’t do serial 7s Gait - Slow, cautious, unsteady wide-based gait, with each step, the foot was thrust outwards and made an audible slapping sound as it struck the floor. Coordination - nl FNF and HTS CN intact Sensory - Diminished pinprick sensation in a stocking-and-glove distribution (to wrist and to ankles). Vibration and proprioception sense loss in both lower extremities from the waist down. Romberg test showed patient able to stand with feet together with eyes open, but fell with eyes closed. Motor - nl bulk, increased tone in BLE, no abnl movts, 5/5 in all ext bilat except bilat iliopsoas 4/5 Reflexes - DTRs 3+ in all bilat except 2+ in ankles, toes upgoing bilat

44y/o RH WF with PMHx of HTN presented to the ED with a history of 3d of HA and gait unsteadiness as well as blindness over several hours, denies other symptoms. Meds: She doesn’t know what medications she takes. Soc Hx: Denies substances abuse FamHx: non-contributory General: HR 102 BP: 186/96, afebrile, RR 14 unlab; general exam benign Neurological: MS - anxious, alert and oriented, no dysphasia; able to give a detailed hx Gait - ataxic gait, wide based, no falling to any one side; not able to tandem/heel or toe walk due to unsteadiness Coordination - FNF and HTS no dysmetria CN – vision limited to light perception only; PERRLA, fundi - unremarkable Sensory - intact to all modalities Motor – normal Reflexes - 2+ and symmetric bilat; toes down

41 y/o WM, previously in excellent health, brought to the ED confused, sometimes agitated. He is a wealthy businessman from Texas visiting NYC for meetings. He was last seen by his colleagues leaving dinner the previous evening for some local entertainment. The following morning, he was found in the wrong hotel room wandering in a confused state. Meds: none FH/PMH and SH: not obtainable. General: P 120 BP 120/80 R 14 T 39°C, skin flushed and dry Neurological: MS – delirious, appears to be hallucinating, no meaningful response to commands CN – pupils 7 mm bilaterally, minimally reactive DTR – hyperreflexic throughout