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NEUROLOGY CASES weakness and difficulty walking.

She tried to
(By Zach London and Aaron Boster) “sleep it off” overnight, but her symptoms
continued the next morning, and her friends from
Case 1: the convent brought her to the emergency room.
A 72 year old retired beekeeper with a history of On physical examination, she was afebrile with a
hypertension presented with sudden onset of blood pressure of 140/80 and a heart rate of 86.
word-finding difficulty and weakness of the right She had a prominent carotid bruit on the right
arm that started approximately 45 minutes prior side. Her left face, arm, and leg were weak,
to presentation. On examination his blood although her face and arm were much weaker
pressure was 148/82 and heart rate was 80. His than her leg. She had some decreased sensation
speech was nonfluent, and he had difficulty with on the left side, and extinction of left-sided
both naming and repetition. He had a right facial stimuli to double simultaneous stimulation. She
droop, and pronator drift of the right arm. had an incomplete left homonymous
hemianopsia and poor left conjugate gaze.

Case 2: Case 6:
A 62 year old man said that he woke up with A 62 year old man with hypertension, diabetes,
difficulty seeing out of his left eye. He reported a and hyperlipidemia was walking into the VA
history of hypertension and paroxysmal atrial hospital, where he works as a custodian, when he
fibrillation, but had not been taking any had the sudden onset of vertigo, nausea, and
medications. On examination, his blood pressure hiccups. On physical examination, his blood
was 180/94, and his heart rate was 125 and pressure was 180/100. He was noted to have left
irregular. The only neurologic abnormality on facial numbness, as well as left ptosis and
examination was a left homonymous miosis. He was dysarthric and had difficulty
hemianopia. swallowing. His left arm and leg were also
ataxic.
Case 3:
A 60 year old diabetic woman was brought to the Case 7:
Emergency Room by paramedics. She stated that A 31 year old yoga instructor presented to the
when she woke up that morning and tried to get emergency room at the urging of her husband.
out of bed, she fell down and was unable to get She reported five days of pain in her left neck
up again. She had trouble moving her right arm and the back of her head that came on the day
and leg. On examination, her blood pressure was after she underwent chiropractic manipulation of
170/92 and her heart rate was 90. She was alert her neck. She called the chiropractor, who told
and oriented, with normal speech and language. her that her symptoms were caused by “her
She had hemiparesis involving the right face, nerves realigning themselves” and that she
arm, and leg. Sensation was normal. She had an needed more frequent manipulations. However,
extensor plantar response on the right. over the last 24 hours, she had also begun to
experience some vertigo, nausea, and left facial
Case 4: numbness. Her neurologic examination was
An 80 year old man came to clinic reporting significant for decreased pinprick sensation in
episodic loss of vision in the left eye. He stated the second division of the left trigeminal nerve.
that each episode began suddenly, and gradually She also had right beating nystagmus in all
worsened over the course of 15-20 seconds, “like directions of gaze and weakness of palate
a shade being drawn over the eye.” The visual elevation on the left. The examination was
loss had always resolved completely within 5-10 otherwise normal.
minutes and was not associated with any pain or
other neurologic symptoms. His examination Case 8:
was normal. A 58 year old man with a history of smoking,
hypertension, diabetes and TIAs presented with
Case 5: six hours of numbness affecting his left face, arm
A 72 year old nun presented in the emergency and leg. His examination was significant for a
room with approximately 14 hours of symptoms. blood pressure of 158/94, and decreased
Her friends stated that she was in her usual state sensation to all modalities on the left side. He
of health until the previous afternoon. She had had no weakness or other neurologic deficits.
been bowling, and suddenly noted left-arm
Case 9: minor head traumas, sometimes associated with
A 90 year old woman with a history of brief loss of consciousness and brief retrograde
hypertension and mild dementia stopped taking amnesia. He reported that during the last two
her lisinopril approximately six months ago months, this had been happening more
because her doctor went out of town the week frequently, and the amount of trauma required to
she needed a refill. She presented to the bring on each episode was less and less. Once,
emergency room with headache, balance he was tackled and “blanked out” even though
problems, and incoordination of her limbs, as his head barely hit the ground. His father stated
well as some vertigo and nausea. On that his teachers had seen him “zone out” during
examination, her blood pressure was 230/118, class. He came to the clinic because his coach
and she was profoundly ataxic. Initially, she was was threatening to cut him from the team.
awake and alert, but over the course of the next
hour, she became progressively obtunded to the Case 13
point that she would not open her eyes and A 14 year old girl was run over by a float in the
would only moan when stimulated. CT scan of 4th of July parade in a small town. She lost
the head showed a large hyperdensity in the consciousness for several minutes. When she
cerebellar vermis with obliteration of the fourth woke up, she was paraplegic and had no feeling
ventricle and some evidence of cerebellar in her lower extremities. She was initially
tonsilar herniation. admitted to an outside hospital, but was
transferred to the University of Michigan after
Case 10 about three weeks because of blood pressure
A 19 year old University of Michigan fluctuations. On physical examination, she had
cheerleader received a blow to the left temple normal strength in the upper extremities and 0/5
when he dropped one of the female cheerleaders strength in both lower extremities. Pinprick
and her elbow collided with his head. He lost sensation was decreased below the level of the
consciousness briefly, but recovered fully. She umbilicus bilaterally. Reflexes were 2+ and
was taken to the emergency room to have her symmetric in the upper extremities, 3+ at the
elbow stitched up. Overcome with guilt, he knees, and 4+ at both ankles with sustained
decided to drive her there. While they were in clonus and bilateral extensor response to plantar
the waiting room, he started experiencing a stimulation.
severe headache. He was put into a room, but
when a nurse came to check on him 30 minutes Case 14
later he had impaired consciousness and dilation A 36 year old HIV positive woman presented to
of the left pupil. the Emergency Room complaining of severe
lower back pain and paresthesias in her buttocks
and legs. She had an episode of urinary
Case 11 incontinence in the waiting room. On
A 28 year old woman came into clinic with her examination, she was febrile (103.3) and
boyfriend, complaining of intermittent headaches diaphoretic. Her low back was exquisitely tender.
for almost three months. The headaches started a Strength was 3/5 in both lower extremities with
day or two after one of her kickboxing students bilateral extensor plantar responses. Her white
kicked her in the head. Over the last few weeks, blood cell count was 26,000/uL.
the headaches have become more constant and
more severe to the point that she had to cancel Case 15
the rest of her kickboxing classes. Her boyfriend A 66 year old man underwent an elective repair
stated that she was drowsy all the time, and of a large abdominal aortic aneurysm. Three days
would sleep all day if not awakened. On later, you received a call from the vascular
examination, she was irritable and would say surgery service. They stated that the patient had
only that she had a headache. Her left face, arm, not moved his legs since waking up from the
and leg were moderately weak, and she had surgery. On examination, he had a Foley catheter
hyperreflexia on the left side. in place. Strength was 5/5 in the upper
extremities and 0/5 in the lower extremities. He
Case 12 had decreased pinprick sensation below the
A 17 year old boy was brought to clinic by his midthoracic region bilaterally. Vibration and
father. The patient is a fullback for the local high position sense were intact throughout. Lower
school team. Last season, he suffered multiple extremity reflexes were brisk and symmetric,
and his toes were upgoing to plantar stimulation stimulation. Plain films of his back demonstrated
bilaterally. a fracture dislocation in his mid-lumbar spine.

Case 16 Case 20
A 23 year old man was in a motorcycle accident. A 58 year old tugboat captain with a long history
He was not wearing a helmet. He did not lose of chronic low back pain presented to clinic
consciousness. On presentation to the emergency complaining of new shooting pains in his leg. He
room, he complained of left shoulder pain and an stated that the pain began in the low back and
inability to move the fingers of his left hand. On radiated down the back of his left leg, across the
physical examination his right pupil was larger knee, and down to the top of the foot. On
than the left. He had a mild left ptosis, and examination, his shooting pains were reproduced
sensory loss along the ulnar aspect of his left when his hip was flexed with the knee in the
arm. He had moderate weakness of the intrinsic extended position. He had mild weakness of left
muscles of his left hand. foot dorsiflexion and toe extension. Ankle
inversion and eversion were also weak,
especially inversion. Patellar and Achilles
Case 17 reflexes were 2+ and symmetric, and toes were
A 46 year old man has been experiencing neck downgoing to plantar stimulation.
and shoulder pain radiating down his radial
forearm for the past month. It came on gradually, Case 21
and has slowly been getting worse. On physical A 66 year old man with along history of mild
examination, strength was 5/5 throughout except low back pain reported that for the past 2
for right elbow flexion (4/5), right supination months, he had been experiencing debilitating
(4+/5) and right wrist extension (4+/5). He leg pain (left greater than right), that would only
reported altered sensation along his right radial occur after he had been standing for 10 minutes
forearm, thumb, and index finger. Biceps and or longer. The pain was located primarily in the
brachioradialis reflexes were 2+ in the left arm buttocks and upper legs, and would gradually get
and 1+ in the right arm. Otherwise, all reflexes better after sitting or resting for several minutes.
were 2+ and symmetric. On physical examination, tone, bulk, and power
were normal in the lower extremities. Deep
Case 18 tendon reflexes were 2+ and symmetric at the
A 34 year old woman was moving a refrigerator knee and 1+ and symmetric at the ankles.
into her first house when she felt a sudden “pop” Ultrasound examination of the blood flow in his
in her neck. She immediately developed soreness legs was normal.
in her neck which radiated down her left arm.
She presented to clinic a week later complaining Case 22
of the same symptoms. On examination, strength A 51 year old female weaver seeing her primary
was 5/5 throughout except for the left triceps and care physician mentioned that her hands had
finger extensor muscles, which were 4/5. been numb for the past two years. The numbness
Sensation was mildly impaired to light touch and was most prominent in her left thumb and was
pinprick over the posterolateral arm and into her exacerbated by working her loom. She also
2nd, 3rd, and 4th digits. The right triceps reflex was complained about pain and paresthesias in her
diminished. hands and wrists that woke her up at night. On
examination, she had mild weakness of thumb
Case 19 abduction. She had paresthesias and decreased
A 40 year old man was brought to the emergency pinprick sensation, primarily over the left thumb
room by the paramedics after falling 40 feet off a and index finger. Phalen’s test was positive (i.e.,
cherry picker and landing on his back. On arrival when she held her hands together with wrists
he complained of extreme pain in his low back flexed, so that the dorsal aspects of both hands
and leg weakness. He had both bowel and touched, it reproduced her symptoms.) She had
bladder incontinence. On exam, he had profound no Tinnel’s sign (i.e. percussion of the median
weakness of his lower limbs. Hip flexion was nerve at the wrist produced no symptoms.)
3/5, but he had no movement of the knee or
ankle. He was areflexic in the lower extremities Case 23
with downgoing toes bilaterally to plantar A 44 year old veteran, who worked as a
firefighter, came to clinic because of impaired
strength and dexterity in his right hand. He had was normal and the rest of his neurologic
always been a very athletic man, but over the last examination was unremarkable.
few months he could not lift free weights with
his right hand without dropping them. Case 27
Sometimes, he would get numbness between in A 55 year old man with hypertension and
the fifth digit of his hand when he flexed his diabetes presented with the sudden onset of
right elbow. On physical examination, he had painless horizontal diplopia that was worse with
marked atrophy of the interossei and the left gaze. On examination, there was esotropia in
hypothenar muscles in the right hand. Prominent primary position, worsened by left gaze. On
weakness of finger abduction was noted. He had testing of ocular pursuit movements, the left eye
decreased pinprick sensation along the palmar did not abduct fully, but other eye movements
surface of the small finger and the ulnar half of were within normal limits. The remainder of the
the ring finger. Reflexes were intact. cranial nerves were intact, and the rest of his
neurologic examination was unremarkable.
Case 24
A 55 year old woman came to urgent care clinic Case 28
and explained that she had awaked with right A 34 year old woman with a history of
arm weakness three days earlier. The night polycystic kidney disease presented with the
before she had been drinking heavily, and she sudden onset of headache and oblique diplopia.
fell asleep on her right side with the arm flexed On physical examination, the patient had a
at the elbow. On physical examination, she had dilated, poorly reactive right pupil. The right eye
2/5 strength in her right wrist and finger was deviated down and out, and had impaired
extensors, and 3/5 strength in her right adduction, elevation, and depression. The left
brachioradialis. Elbow extension was 5/5. eye moved normally. The remainder of the
Pinprick sensation was reduced over the right neurologic examination was within normal
first dorsal web space. Deep tendon reflexes limits.
were trace and symmetric throughout the upper
and lower extremities. Case 29
A 51 year old ventriloquist came to clinic
Case 25 reporting periodic “attacks” of facial pain for the
A 42 year old woman underwent an elective previous four months. He described momentary
breast reduction surgery. After waking from bursts of severe, unilateral, “stabbing” pain in his
general anesthesia, she noted weakness of the right cheek that came on spontaneously or with
right foot, and also numbness and tingling over certain stimuli, such as brushing his teeth or
the dorsum of the right foot. She was discharged shaving. Despite avoiding these activities, the
with an appointment in the outpatient neurology attacks had increased in frequency and at the
clinic. When she was seen there two months time of presentation were occurring almost daily.
later, there had been no significant change in her Physical examination is normal.
symptoms. On examination, there was 4/5
weakness of ankle dorsiflexion and eversion. Case 30
Ankle inversion was 5/5. She had decreased A 68 year old man with a history of
pinprick sensation over the dorsum of the right hyperlipidemia and smoking was brought in by
foot. Reflexes were 2+ and symmetric the paramedics after suffering from a single
throughout. generalized tonic clonic seizure that lasted about
2 minutes. By the time you saw him in the
Case 26 emergency room, he was back to his baseline.
A 28 year old previously healthy man was half His wife then confided in you that he had been
way through his dental hygienist board exam acting “funny” for about a month. He had been
when he noticed that his left lip seemed to be belligerent with family members and had been
sagging and he had difficulty closing his left neglecting basic hygiene. He had also been
eyelid. He finished the examination and drove incontinent of urine on more than one occasion
himself to the emergency room. On physical and did not seem to care. He has lost 30 pounds
examination, he had left facial weakness with since his last doctor’s appointment six months
flattening of the nasolabial fold and partial ago. His exam was normal except for
paralysis of eye closure. He was unable to papilledema in both eyes, pronator drift of the
wrinkle his forehead on the left. Facial sensation left arm and a hacking cough.
Her only other neurologic symptom had been a
Case 31 partial loss of vision in her left eye eight months
A 50 year old woman with no significant past ago. That had developed gradually over 4 days
medical history presented with complaints of and resolved over a few weeks; she had
episodic dizziness, tinnitus, and mild right-sided attributed it to the stress of owning a new puppy
hearing loss. These symptoms had become and starting a new job. Her examination was
progressively more frequent and more severe normal except for a left afferent papillary defect
since onset. The patient had a normal general and mild hyperreflexia in her left lower
physical examination and no abnormalities on extremity.
neurologic examination other than the hearing
loss in her right ear. MRI showed a 1.5 cm Case 36
enhancing mass in the right cerebellopontine A 50-year-old right handed man woke with the
angle, with a tail that entered the internal sensation of numbness and tingling over his legs
auditory canal. and trunk to the level of his nipples. He was able
to walk with some difficulty, stating he could not
Case 32 feel his feet. The next day his legs began to feel
A 60 year old man presented because of daily stiff and tight. Two days later he experienced
headaches for about six weeks. He said that he urinary retention. On physical exam his arms had
had been awakening every day with a headache, normal strength, sensation and reflexes. He had
and the need to vomit. About two weeks ago, he decreased sensation below his nipples, increased
had begun to have word-finding difficulties, as tone in his legs, and brisk lower extremity
well, and could no longer work as a cattle reflexes. Plantar responses were extensor
auctioneer. On physical examination, he had bilaterally. Rectal tone was poor.
bilateral optic disc edema. He was able to name
4 out of 8 objects, and could not repeat the Case 37
phrase, “Shiver Me Timbers.” He had pronator A 42 year old female first developed leg
drift of the right arm. Neurologic examination weakness and spasticity about 8 years ago. She
was otherwise normal. went from walking independently to being
wheelchair bound over the course of two years.
Case 33 After that, she noticed that her right arm started
A 4 year old boy presented to clinic with four to become stiff and weak. At the time of
weeks of headaches and three days of nausea and presentation, she was unable to feed herself, and
unsteadiness. On physical examination, the required intermittent urinary catheterization. She
patient was awake but sleepy and irritable. He complained of blurred vision, especially when
had bilateral papilledema. He had significant looking to the left, and “electric shock-like pain”
truncal ataxia and bilateral dysmetria. down her spine with neck flexion. She also
complained of profound fatigue, which is worse
Case 34 during the hot summer months. On her physical
A 20 year old assembly line worker at a exam, she had impaired adduction of the right
Johnson’s Jigs and Fixtures presented with three eye. She was weak and spastic in all four
months of galactorrhea. She reported five years extremities, with hyperreflexia and upgoing toes
of amenorrhea, with irregular menses before that, to plantar stimulation bilaterally.
starting at age 13. She reported occasional
headaches, but had no other symptoms. On Case 38
physical examination, she had bitemporal An 8-year-old girl was noted by her teacher to be
hemianopia on confrontation testing of visual intermittently inattentive in the classroom. She
fields. would stare with a blank expression on her face
for several seconds at a time. She would not
Case 35 respond to her name being called and sometimes
A 30-year-old woman was referred by her had rapid fluttering movements of her eyelids.
internist because for the previous 3 weeks, her Once the staring ceased, she would immediately
left foot had a tendency to drag after the fourth return to baseline. Her pediatrician was able to
mile of her daily 5-mile run. Four years ago she provoke one of the spells by having the child
had a similar problem with her right foot, but had hyperventilate in the office. Physical
attributed it to a twisted ankle, and the symptoms examination was normal.
had spontaneously resolved over the next month.
Case 39 spells. Her mother, who had witnessed many of
A 27-year-old man began to experience these spells, stated that after falling to the
stereotyped spells, that always started with an ground, her head would shake from side to side
unpleasant sensation in his abdomen. He would and her pelvis would thrust wildly. She did not
then become unresponsive to those around him experience any oral trauma or incontinence of
and start staring and picking at his shirt buttons. urine during the spells. The spells lasted
Next, he would fall to the floor and have approximately 1 to 2 hours and only occurred
generalized stiffening of all four extremities after dinner. Examination at the time of
followed by shaking rhythmically for 30 presentation was normal.
seconds. He often bit his tongue during these
spells and was usually incontinent of urine. Case 43
Afterwards, he was confused for approximately A 33 year old man with a known right frontal
1 hour. The patient’s most recent spell was two astrocytoma experienced sudden uncontrolled
weeks ago. Physical examination today was twitching of the fingers of his left hand. The
normal. twitching progressed to include the entire hand,
followed by the arm and shoulder over the
Case 40 course of one minute. It than subsided after
A 34-year-old woman on phenytoin for a history another minute. He remained conversant and was
of complex partial seizure disorder was in her fully conscious during the entire event.
usual state of good health when she was
witnessed to have a generalized tonic-clonic Case 44
seizure in the pet store one afternoon. When A 30-year-old woman came to the emergency
EMS arrived, the patient had a second room because of severe headache for the
generalized tonic-clonic seizure. EMS reported previous eleven hours. She first started having
generalized stiffening of all four extremities headaches when she was in high school, but they
followed by clonic movements, cyanosis, used to occur only about four times a year. In the
frothing at the mouth, and urinary incontinence. last year the frequency had increased, and the
The patient has 1 more seizure without patient now had headaches up to twice a week.
recovering consciousness before reaching the All of her headaches started on one side (usually
local emergency room. the right) and progressed to involve the entire
head. The headaches were associated with
Case 41 photophobia, phonophobia, and nausea. Her
An 18-year-old college freshman with no headaches would usually resolve within two
significant past medical history was brought to hours if she would lie down in a dark room and
the emergency department because of a take acetaminophen. Her current headache was
generalized seizure. He had completed exams on similar to her previous headaches, but had not
Friday and had been drinking heavily over the improved despite taking six acetaminophen pills.
weekend to celebrate. His friend said that on Her examination was normal.
Saturday night he had passed out in a stairwell,
and shortly thereafter began to have generalized Case 45
shaking movements that lasted almost two A 26-year-old geophysics graduate student
minutes, and he was confused for about a half an reported occasional headaches since her
hour afterward. The patient was back to baseline undergraduate years. They always started with
at the time of presentation to the emergency “squiggly lines” in her visual fields and
room and had no memory of the event. His dizziness. These symptoms resolved in
physical exam was normal. approximately fifteen minutes and were followed
by debilitating pain behind her left eye which
Case 42 radiated to her temple and occiput. She would
A 40 year old woman reported almost daily usually throw up when the pain became severe.
spells ever since a month ago, a few days after Lights and sounds bothered her, and she would
her husband shoved her roughly and told her that usually put a towel over her eyes and try to lie
he wanted a divorce. She described slowly losing still until the headache passed, which was
control of her legs and crumbling to the floor. usually several hours or longer.
She denied loss of consciousness during these
spells, but reported that she was not able to speak Case 46
to people or follow commands during these
A 56-year-old circus worker suffered from 4 in the process of moving to a new house, and the
weeks of explosive headaches. He stated that stress associated with the move seemed to make
they would come on very suddenly each day at her headaches worse. She was otherwise in good
2:00am. The headaches were only on the right health, and denied nausea, vision changes,
side of his head, and were associated with numbness or tingling, neck stiffness, or fevers.
tearing of his right eye and right nasal congestion
and discharge. They typically lasted 45 minutes, Case 51
during which time he would go back to his trailer A 46 year-old man was brought to the emergency
and bang his head against the wall. He was room by his brother for evaluation of headaches
usually pain-free by 3:00 am and able to fall and fever. He had been sick for a couple days
back to sleep, but he then had trouble waking up with a “sinus infection,” but on the day of
in time to feed the lions at 5:00am. He had presentation, he developed a severe headache. In
experienced the exact same thing several years the emergency room his temperature was 104
ago, and the episodes had abated after about two degrees F. He appeared to be very
months. uncomfortable. His neck was stiff and very
sensitive to passive manipulation. A head CT
Case 47 without contrast was performed and was normal.
A 19-year-old woman was evaluated by her A lumbar puncture was performed, and the
family doctor for a four week history of opening pressure was elevated. The CSF studies
headaches and a two week history of transient were as follows: WBC 1550 with 80%
blurry vision, nausea and vomiting. She had segmented neutrophils, RBC 10, Glucose 30,
started tetracycline for treatment of her acne Protein 57.
three months earlier. On physical exam
papilledema was present bilaterally. A contrast Case 52
MRI was normal. A 50-year-old retired autoworker was brought to
the emergency room by her husband for
Case 48 evaluation of the worst headache of her life. That
A 78-year-old woman presented with a 2 month morning she had developed a severe bifrontal
history of superficial head and face pain, headache with neck stiffness and light sensitivity.
maximal over the left temple and suboccipital She had vomited twice in the car en route to the
region. She also noticed that after a few seconds hospital. On exam she was febrile to 101 degrees
of chewing bubble gum, she would experience F and in mild distress. Her neck was stiff and
jaw pain. The pain would resolve as soon as she very sensitive to passive manipulation. Her discs
stopped chewing. Blowing bubbles did not were flat on funduscopic exam, and the
exacerbate the pain. On examination, her scalp remainder of her neurologic exam was normal.
was tender to the touch over the left temple. Head CT showed no bleed. A lumbar puncture
was performed, and the opening pressure was
Case 49 within normal limits. CSF studies were normal
A 33 year-old female with newly diagnosed except for a WBC of 8 with lymphocytic
hypertension presented to the emergency room predominance.
several hours after suddenly experiencing a
severe headache, photophobia, stiff neck, and Case 53
nausea. She denied concurrent illnesses. A 52 year old homeless woman with diabetes
Temperature was 98.0 degrees. Blood pressure in was found unresponsive in an off-duty bus. On
the emergency department was 220/110. She exam, temperature was 104 degrees F. She had
became obtunded in the emergency room, and poor dentition with carious teeth and exudative
within an hour she no longer followed lesions in her gums. She did not respond to
commands or produced any spontaneous speech. visual or auditory stimuli; to painful stimuli she
On cranial nerve exam her left pupil was dilated would moan and withdraw her left leg, but not
and poorly reactive to light. her right. Funduscopic exam revealed mild
papilledema on the left. Plantar response was
Case 50 extensor on the right. During the examination,
A 55 year old woman presented with ongoing the patient had a 30 second generalized tonic
headaches, occurring once or twice a week. She clonic seizure.
described a vice-like squeezing pressure across
her forehead and the back of her neck. She was Case 54
A 38 year old woman had a fifteen minute period after a nap, in which he was unable to move or
of hypotension during a mitral valve repair speak for seconds to minutes, even though he felt
surgery. After the surgery, the patient was wide awake. His physical examination was
“unresponsive,” so neurology was consulted. On within normal limits.
physical examination, the patient’s eyes were
open and pupils were responsive to light. Case 58
Respirations were intact. She did not speak and A 60 year old man was brought to clinic by his
did not respond to voice. She did not track wife, who claimed that he had been “acting out
objects but did appear to look randomly around his dreams” for several years. Sometimes he
the room. The medical staff noted that she had would scream and kick, or even fall out of bed
sleep-wake cycles. Motor tone was flaccid. and start flailing his arms violently. One time, he
actually punched her repeatedly while he was
Case 55 sleeping. If she tried to wake him up, he would
A 20 year old was using a chainsaw to cut high awake immediately, and describe a dream that
branches near his house when he cut through a correlated with his actions. Physical examination
high voltage power line. He fell from the ladder was within normal limits.
and was immediately unresponsive. The
paramedics were called to the scene and found Case 59
the patient in asystole. He was intubated and An 80 year old woman with a history of chronic
cardioverted back to normal sinus rhythm after obstructive pulmonary disease (COPD), diabetes
being down for approximately 20 minutes. When mellitus, and chronic low back pain was brought
he arrived in the emergency room, he was in from the nursing facility where she lived
unresponsive to all stimuli, including sternal rub. because of mental status changes. Her caregivers
He took no spontaneous breaths. His pupils were stated that at baseline, she was alert, conversant,
fixed and dilated in mid-position. His and largely independent. However, on the
oculocephalic and vestibulo-ocular reflexes were morning of presentation, she was found to be
absent. Gag and corneal reflexes were also confused and irritable, and “She kept saying the
absent. Deep tendon reflexes were intact. Head F-word.” On examination, her temperature was
CT and basic laboratory studies were all within 99.0, her blood pressure was 94/50, and her
normal limits. The next day, his exam was oxygen saturation was 92% on room air. She had
unchanged. waxing and waning alertness, and was not
oriented to place or time. She was sleepy, and
Case 56 very uncooperative with the exam. Cranial
A 49 year old man came to clinic because of nerves were intact and she was moving all four
excessive daytime somnolence for approximately extremities equally. Her reflexes were
six months. He reported that he slept at least symmetric, but when you tried to test them, she
seven hours a night, but in the mornings he felt said the F-word. Examination was otherwise
“unrefreshed and headachey.” His wife normal.
accompanied him today, and started that she had
started sleeping in a different room because he Case 60
was a loud snorer. She also noted that he often A 77 year old woman was brought to clinic by
“stopped breathing” for several seconds at a time her family because of “short-term memory loss.”
during his sleep. On physical examination, the Her son noted that the patient began having
patient was overweight (242 pounds) with no problems with her memory about three years
focal neurologic deficits. ago. Specifically, she was misplacing things,
forgetting the names of acquaintances, and
Case 57 having difficulty managing her own finances.
A 29 year old man reported that he had been Over the last year, she began getting lost while
“falling down” frequently over the last five driving, confusing the names of her own
years. He said that when he heard a funny joke children, and wearing dirty clothing. On
or got angry about something, he would cognitive examination, she was oriented to the
gradually collapse to the ground. He reported year but not the date or month. She knew she
excessive sleepiness and the need for frequent was in a doctor’s office but did not know what
naps during the day. He also reported vivid town it was in. She could not recount any recent
hallucinations while falling asleep. He also major news events. She was able to name a
described some terrifying episodes that occurred finger and a watch, but not a thigh or a lapel. She
was able to draw a clock, but could not draw the A 12 year old boy presented to clinic with a two
hands to indicate 10:15. She could repeat three year history of abnormal behaviors. His mother
words, but could not recall any of them after five said that the first thing that she noticed was
minutes. General neurologic examination was episodic blinking and eye rolling. After a few
normal. months, this gradually subsided but was replaced
with episodes of twitchy shoulder shrugging. A
Case 61 few months later he developed episodes of
A 50 year old man was brought to clinic by his grunting, tongue clicking or humming. The
family who felt he was depressed. Over the last patient stated that he had a very strong desire to
two years, he had become socially withdrawn. perform each tic, but could overcome that desire
He had made inappropriate comments to his for a short period of time if he tried. On
family, including comments of a sexual nature to examination, the patient had multiple episodes of
strangers. He had locked his dog in the basement eye-blinking during the examination, and
without food for three days because “it was occasional grunting. The remainder of his exam
getting fat.” Over the last six months, his family was normal.
had noted progressive cognitive decline, as well.
The decision to seek medical attention was Case 65
prompted by an episode two months ago when A 16 month-old girl was referred by her
he was arrested for taking his clothes off in a pediatrician for evaluation of leg weakness and
Taco Bell. On cognitive testing, he had profound hand tremors. She was the product of normal
difficulty with naming and abstract reasoning, pregnancy and uncomplicated vaginal birth. The
and mild memory impairment. General patient was crawling by 9 months and since
neurologic examination was otherwise normal. about 12 months she was able to walk holding
onto furniture. However, she never developed the
Case 62 ability to walk independently. On neurologic
A 70 year old man presented to clinic with three examination, cognition was normal for age. She
years of progressive cognitive decline. His wife had decreased tone and strength in all four
tells you, “Some days he seem fine and other extremities, most prominently in the lower
days his thinking is way off.” She reported that extremities. There were no sensory
some days, he had hallucinations of children abnormalities. Reflexes were completely absent
walking around the house, or cows grazing in throughout.
their yard. Over the last six months, he had
begun to move more slowly. On cognitive Case 66
examination, he had mildly impaired orientation An 8 year old boy was brought to the
and verbal recall. He was completely unable to pediatrician because of a “lazy left eye” over the
draw interlocking pentagons or mimic sequential past six weeks. Other than a mild learning
hand gestures. On general neurologic disability, he had no significant past medical
examination, he had a somewhat masked face. history. On examination, he had decreased visual
He had mild cogwheel rigidity in both upper acuity in the left eye (20/200) with a left relative
extremities. He performed fine finger afferent pupillary defect, temporal visual field
movements slowly and clumsily. No tremor was deficits, and a pale optic disc. Small hematomas
present. He had a slow, shuffling gait. and nodular clumps of pigment were noted in
both irises. His general examination was
Case 63 significant for axillary freckling and
A 70 year old man with a history of hypertension approximately ten café au lait spots on his back,
presented to clinic with two years of progressive chest, and extremities. An MRI of the patient’s
memory and balance problems, as well as recent brain showed an enhancing-mass on the
onset of urinary incontinence. On cognitive proximal portion of the left optic nerve.
examination, the patient had impaired memory,
was unable to perform simple calculations, and Case 67
could not draw interlocking pentagons. A 6 year old girl presented to clinic with lifelong
Language was normal. On general neurologic stiffness and weakness in both legs. She had
examination, the patient had a slow, wide-based been born five weeks prematurely via breech
gait. delivery. She was delayed in all major motor and
cognitive milestones, but had not regressed in
Case 64 any way. On physical examination, the patient
had profound spasticity in both legs, with clonus coffee. It was worse with stress and better with
at both the knees and ankles and upgoing toes to alcohol. Therefore, she frequently drank 2-3
plantar stimulation. ounces of vodka before having dinner with her
in-laws. On physical examination, the patient
Case 68 had a high amplitude 6-Hz postural and kinetic
A 7 year old boy was brought to clinic with new tremor that extinguished with rest. Muscle tone,
onset seizures. His parents noted that for the last limb coordination, posture and gait were all
two years he had a short attention span and normal.
difficulty following instructions. Over the last
year, his speech had become progressively Case 72
slurred, and he had intermittent urinary and A 28 year old woman with a ten year history of
bowel incontinence. His cognition had also bipolar disorder was referred to neurology clinic
declined. He had a past history of intermittent by her primary care doctor for evaluation of
vomiting and dehydration since he was two years “tics.” The patient’s husband reported wildly
old, and his skin had been excessively tan since fluctuating mood changes and progressively
he was four years old. On physical examination, impaired cognition over the last five years. On
he had poor visual acuity and a spastic examination, she had mild dysarthria.
dysarthria. Strength was within normal limits, Involuntary distal twitching and dancing
but the patient’s reflexes were diffusely brisk, movements of her hands and toes were noted.
and he had upgoing toes bilaterally. Her gait was broad-based and she was unable to
walk in tandem.
Case 69
A 6 month old boy was brought to the emergency Case 73
room by his mother, who reported that he fell out A 15 year-old girl presented to the clinic with six
of his crib onto his head the night before, and months of progressive cognitive decline,
had been “acting weird” since then. He had been irritability and tremor. On examination she had
feeding poorly and vomited several times. On hypersalivation and diminished facial
general exam, the baby has bruises on his head, expression. Irregular regions of muddy brown
shoulders, and neck. He was lethargic and discoloration were present on her corneas. She
irritable. His head size was increased and his had a wing-beating tremor and impaired
fontanel was tense. Retinal hemorrhages were handwriting.
noted bilaterally on funduscopic examination.
Case 74
Case 70 A 41 year-old woman presented with a ten year
A 71-year-old man complained of “shakiness” history of involuntary head rotation to the right.
in his left hand beginning 8 months ago. He It was present at all times, but exacerbated
was otherwise in good health and taking no periodically by a sharp jerking movement to the
medications. He provided a clear, concise right. The involuntary movements were
history. On exam his face was expressionless exacerbated by anxiety. She was on no
and he blinked infrequently, although his facial medications. Other than the episodes that she
muscles activated symmetrically. He had a described, her physical examination was normal.
prominent resting tremor of his left arm that
improved with volitional movement. There was Case 75
some cogwheel rigidity on the left and A 60-year-old man with no past medical history
impaired rapid movements of the left hand. He stated that his speech had become progressively
had a stooped posture and took small shuffling more unintelligible over the last year. Recently,
steps. Arm-swing was decreased on the left, he began having problems with “food going
and the patient took six steps to turn around. down the wrong tube.” He also noticed that he
was having difficulty with walking and his hands
Case 71 and feet were getting tired more easily. On
A 50 year old woman presented to clinic physical exam, fasciculations were noted in his
complaining of tremor in her hands. The tremor tongue, trapezius, and quadriceps muscles. He
had been present for about three years, and had had atrophy in the intrinsic muscles of his left
gotten worse over the last six months. It was hand and right foot and weakness in these areas.
present equally in both hands and she noticed it Reflexes were 3+ diffusely, with an upgoing toe
most when trying to hold a magazine or a cup of
on the left to plantar stimulation. Sensory exam that when she woke up in the morning, she felt
was normal. fine, but as the day wore on, she would develop
horizontal diplopia. She also reported episodic
slurred speech and swallowing difficulties. On
Case 76 physical examination, she developed bilateral
A 58 year old boiler inspector from Gary, Indiana ptosis after trying to sustain upgaze for 30
presented to clinic for evaluation of numbness second. Examination was otherwise normal.
and pain in his feet. The symptoms started
approximately five years ago in his toes, and Case 80
gradually spread to involve both feet. He A 4-year-old boy was brought to his pediatrician
described the pain as burning in nature, and more because of gait abnormality. He was the product
bothersome at night. He said he was in perfect of an uncomplicated birth and delivery. He did
health and had not seen a doctor since his army not walk until 18 months of age, and when he
physical at age 20. On physical examination, he did start walking, he would walk on his tiptoes
had decreased pinprick sensation below midshin and waddle. His parents reported that he fell
and absent vibration and position sense below frequently and had difficulty getting up. On
the ankle. Upper extremity reflexes were 2+, physical examination, he had large calves. He
patellar reflexes were 1+, and ankle jerks were was weak in the deltoids, biceps, and hip girdle
absent. The patient’s gait was mildly wide-based muscles, but relatively strong distal muscles.
and Romberg sign was positive.

Case 77 Case 81
A 30-year-old man presented to the emergency A 50 year old man reported weakness and fatigue
room with lower extremity tingling and difficulty for the past 2-3 months. He was having
walking. He developed back pain and toe progressively more difficulty with certain tasks
tingling three days prior, and the other symptoms such as combing his hair, lifting his brief case, or
had progressed since then. On examination, he climbing stairs. He initially denied talking or
had mild bilateral facial weakness and weakness swallowing problems, but eventually admitted
of all four extremities distally, with relative that he choked a few times when trying to eat
sparing of the proximal muscles. Sensation was steak too fast. He had no problems with fine
intact, but the patient reported “abnormal motor activities, such as buttoning his shirt or
sensations” distally in all four limbs. Reflexes writing. On physical examination, the patient had
were absent throughout. 4/5 strength in neck extension, as well as the
proximal muscles of his upper and lower
Case 78 extremities symmetrically. Sensation and
A 40 year old man presented because of reflexes were normal.
progressive leg weakness. He stated that he had
always had high-arched feet, and as a child, he
was always the slowest runner and could not ice
skate. When he was a teenager, he began to have
more problems with his feet and his ankles
would sometimes give out on him for no reason.
During the last two years, he noticed progressive
numbness in his feet. He had been tested for
diabetes, but did not have it. On examination, he
had wasting of the intrinsic hand muscles and
calves with a pes cavus deformity. Strength was
full proximally, but 4/5 in the intrinsic muscles
of the hands and feet. Temperature and pinprick
sensation were diminished to mid-calf and the
wrist. He was areflexic. Romberg sign was
positive.

Case 79
A 34 year-old woman came to her physician
because of fluctuating double vision. She stated