A 32-year-old woman presents to the neurology clinic with a history of worsening headaches over the past 6 months. The headaches are occipital and exacerbated by coughing. There are no notable neurological findings on examination. The MRI image below reveals what abnormality?
A 14-year-old male presents to your clinic with complaints of increasing fatigue at school over the past 2 months. His parents are worried that he relies on large amounts of Lucozade to stay alert during his secondary school exams. He denies any headaches. The patient had a normal pregnancy and development until he was 12 years old when he underwent chemotherapy and radiotherapy for an optic chiasm glioma, causing him to miss a year of school. He returned to school after treatment and has been achieving good grades. There is no significant past medical or family history.
Upon examination, the patient is short for his age (at 2nd centile) and lacks facial hair or other secondary sexual characteristics. He has a BMI of 13.7 kg/m² and appears thin. Chest, cardiovascular, and abdominal examinations are unremarkable, and there are no skin lesions. Neurological examination, including cranial nerves, is normal.
The initial blood tests reveal the following results:
Hb 142 g/l
MCV 89 fl
Platelets 410 * 109/l
WBC 7.4 * 109/l
Na+ 139 mmol/l
K+ 4.6 mmol/l
Urea 5.1 mmol/l
Creatinine 44µmol/l
FSH low
ACTH low
TSH 0.13 mu/l
What is the most likely diagnosis?
A 50-year-old emaciated male is admitted to the hospital after being discovered on the floor by his sister during her weekly visit. The patient has a long-standing history of depression and has had poor appetite for several years. He denies experiencing any loss of consciousness, chest pain, palpitations, dysphagia, or presyncopal symptoms. He vaguely recalls falling slowly due to weakness and denies any head injury. The patient reports having a recent sore throat and dry cough. He is alert and oriented. Upon examination, he has a power score of 3 and 4 out of 5 in all movements. The tendon hammer fails to elicit lower limb reflexes, but bilateral upgoing plantars are observed. What treatment would be the most effective in rapidly reversing the underlying condition?
A 55-year-old nurse with a 10-year history of working in the operating theatre presents to the Psychiatry Clinic with a complaint of gradually increasing irritability over the past 3 months. According to his wife, he has become suspicious and is convinced that she is having an affair with their neighbour. He recently sold his car at an unusually cheap price and becomes hostile when his mistakes are pointed out. On examination, he appears unkempt and has impaired recent memory. Fundus examination reveals bilateral pale optic discs, and his gait is ataxic and mildly spastic. Power of hip flexors and ankle dorsiflexors is 4/5, and tendon reflexes are depressed with up-going planters on both sides. Vibration is diminished to mid-shins. Investigations reveal abnormal results for WCC, Hb, MCV, MCH, and glucose. However, HTLV 1, VDRL, TPHA, and HIV tests are negative. CSF analysis shows lymphocytes and protein within normal limits, but glucose is elevated. MRI of the cervical spine reveals T2 signal change in the posterior columns. What is the most likely diagnosis?
A 58-year-old man presents to his GP with complaints of left arm pain. He reports experiencing the pain while lifting weights and during exercise, which causes him to feel weak, dizzy, and nauseated. He has even passed out twice without warning. The patient also reports neck pain and recently had an MRI scan that showed some degenerative changes in his vertebrae. He has a medical history of hypertension and hypercholesterolemia and takes atenolol and simvastatin regularly. He is a smoker and drinks approximately 20 units of alcohol per week. He works as a builder and is married with two adult children.
During the examination, the patient’s blood pressure was 150/78 mmHg in the right arm and 120/67 mmHg in the left arm. Bilateral carotid bruits were present, but heart sounds were normal, and the chest x-ray was normal. Neurological examination showed normal tone, depressed reflexes at the biceps and brachioradialis, and a brisk triceps jerk. There was impaired pinprick sensation over the thumb and middle finger in the left hand, but no weakness, atrophy, or fasciculations were observed. The cerebellar system appeared intact.
Carotid Doppler studies revealed 70% stenosis of the left internal carotid artery and 50% stenosis of the right internal carotid artery. Based on these findings, what is the most likely diagnosis for this patient?
A 65-year-old man was brought to the Emergency department after a fall in his bathroom.
Seen immediately by his family, he was already picking himself up from the floor and said he was not injured. His wife felt that he was transiently dazed.
On examination, he was alert, and no abnormalities were noted. His medical history included a history of hypertension for which he was taking bendroflumethiazide 2.5 mg daily. He was discharged without any further intervention.
Two weeks later his wife brings the patient to see you because the dazed state has returned. Examination reveals a temperature of 36.7°C, a pulse rate of 84 bpm regular, a blood pressure of 152/94 mm Hg.
On questioning he is slightly slowed, being disoriented to time with some deficit in recent memory. The patient moves slowly, but power is normal. Neurologic examination shows slight hyperactivity of the tendon reflexes on the right with unclear plantar responses because of bilateral withdrawal.
What tests or evaluations would you request?
A 24-year-old university student presented with a year long history of occipital headache. This was worse on coughing, sneezing and straining and partially relieved by lying flat. On one occasion the headache had been associated with vomiting. She had previously consulted her family doctor who was treating her for migraine. Over the past two months she had noticed pain in her both arms and felt unsteady on her feet.
On examination touching her arms caused pain and there was reduced appreciation of pinprick and temperature sensation throughout both arms. Tone, power and reflexes in the upper limbs were normal. On testing upper limb co-ordination there was some past-pointing and a very mild intention tremor. On inspection of the feet there was pes cavus and Romberg’s test was positive. Again tone, power and reflexes were normal in the lower limbs and plantars were downgoing. Proprioception was impaired with absent joint position sense until the level of the knee. Vibration sensation was impaired in both feet.
Based on the clinical findings described above, what is the most likely diagnosis for this 24-year-old university student?
A 36 year old construction worker presents to the emergency department after sustaining a severe cut to his upper arm while on the job. During the suturing process, the physician notices multiple burns and cuts on both of his arms.
Upon examination, the patient displays significant atrophy of the brachioradialis and small muscles in both hands, along with mild hyporeflexia of the biceps and brachioradialis tendons. He experiences weakness in both arms, particularly distally. However, his lower limb and cranial nerve assessments are unremarkable. Upper limb sensation, vibration, and proprioception are intact, but there appears to be reduced pain and temperature sensation over the C3/C4/C5 dermatomes. What diagnostic test would be most beneficial in this case?
A 42-year-old chef presents to a neurologist with progressive wasting and weakness of the right hand. He has been experiencing reduced dexterity and clumsiness while at work for several months. Additionally, he has burnt his hands while cooking or smoking without realizing it, resulting in multiple sores over the fingertips of both hands. He has no known medical history but did sustain a whiplash injury in a recent minor car accident. On examination, there is evidence of right dorsal interossei, hypothenar eminence, adductor pollicis brevis, and forearm wasting. Power, handgrip, and wrist flexion/extension are asymmetrically weak (right>left). Sensation is reduced for pain and temperature affecting both arms and anterior/posterior chest wall. What is the likely diagnosis for this patient based on the history and examination findings?
An 80-year-old resident of a nursing home presented to the neurology clinic with a history of Alzheimer’s disease. Her behavior had become increasingly challenging over the past four months, leading to the initiation of regular haloperidol. However, the nursing home staff reported that over the last four weeks, she had developed involuntary movements of her mouth, including frequent tongue protrusion and lip-smacking. Despite stopping the haloperidol two weeks ago, her symptoms had worsened. On examination, she displayed continuous involuntary lip-smacking, tongue protrusion, and frequent eye-blinking, but was otherwise well and alert. What is the most likely cause of her symptoms?