A 35-year-old woman comes to the clinic with her 65-year-old mother, who is taking L-dopa for Parkinson’s disease. She expresses concern about her own risk of developing the condition, as her grandmother also had Parkinson’s.
Which of the following symptoms is most commonly associated with early onset Parkinson’s?
A 28-year-old man has been experiencing a gradual onset of bilateral leg weakness for the past 18 months, which has progressed to the point where he now requires crutches to walk. He also experiences intermittent urinary incontinence and falls frequently in the dark due to poor balance. He denies any previous symptoms and has no significant medical history. He works as an accountant and has a history of traveling to the Caribbean, Japan, and Africa in his early 20s. During his travels, he admits to occasional intravenous drug use and getting a tattoo. He also reports having casual sexual contact with sex workers without using barrier contraception. On examination, he has hyperreflexia bilaterally in the legs with upgoing plantar responses and loss of vibration and joint position sense in the legs. His knee and plantar extensors are 3/5 power, while his flexors are 4/5 power. He has a stomping gait. Routine blood tests and HIV screening are unremarkable, but MRI brain and whole spine reveal areas of demyelination in the lumbar spine. What test would you perform to confirm the suspected cause of his symptoms?
A 67-year-old man presents to the emergency department after experiencing a sudden loss of consciousness. He reports having a severe headache earlier in the day, which started at the back of his head and quickly escalated to a 10/10 level of pain.
Upon conducting the following investigations:
– CT head: Blood found in the sulci, fissures, basal cisterns, and ventricles
– Cerebral CT angiogram: Evidence of a ruptured aneurysm in the posterior cerebral artery
What would be the most appropriate initial management for this patient?
A 16-year-old Caucasian male with no prior medical history presents with his first episode of sudden onset left leg weakness and numbness on his anterior left thigh, which has persisted for 5 days. Upon examination, it is noted that he has 3/5 weakness on flexion of his left hip and loss of sensation to light touch, pain, and temperature on his anterior left thigh in the sensory nerve root L1 distribution. A contrast MRI scan of the patient’s spine reveals a hyperintense T2 signal partially within the left side of the cord at the L1, with corresponding enhancement with gadolinium. No masses were observed. Further imaging of the brain is pending. What is the most probable diagnosis at this time?
A 75-year-old male visits the PD clinic with a complaint of uncontrollable jerking and flailing movements in his arm, which he finds embarrassing and disabling. He reports minimal issues with ‘off’ periods and few other PD symptoms. His medical history includes PD diagnosed 6 years ago and type 2 diabetes. He is currently taking Sinemet 250 for Parkinson’s disease 5 times a day and metformin 500mg TDS, with no changes in Sinemet dosage for the past 18 months. What is the most appropriate course of action for management?
A 57-year-old man is brought to the hospital by his wife due to unusual behavior. She found him repeatedly cutting the same shrubs while gardening and he kept asking when dinner would be ready. When he returned to the house, he had no recollection of gardening and continued to ask the same questions repeatedly.
Upon examination, he appears to be well and oriented in time and place, but a little confused about what happened. There are two beats of nystagmus seen, but no ophthalmoplegia. He has normal limb power, tone, and gait, with no myoclonus or fasciculations. His wife reports no memory problems or personality changes prior to this incident. He denies excessive alcohol use, but his father was diagnosed with Alzheimer’s disease at the age of 60.
Lab results show normal electrolyte levels, kidney function, and blood counts, but low levels of B12 and slightly elevated bilirubin and ALP. A CT scan reveals age-related changes and old lacunar infarcts on the left side, but no intracranial hemorrhage.
What is the likely diagnosis for this 57-year-old man’s unusual behavior?
A 67-year-old man presents to the Emergency Department with sudden memory impairment that started 3 hours ago. His wife reports that he became disoriented after taking a cold shower and complained of a mild headache. On examination, his vital signs are stable and he is alert but disoriented in place and time. He can recall his identity but has difficulty remembering three objects after 3 minutes. There is retrograde amnesia for several hours. The following day, he has fully recovered and all laboratory tests are normal. What is the most likely diagnosis?
A 67-year-old man presents to neurology clinic for evaluation of his long-standing trigeminal neuralgia. He has been experiencing symptoms for five years and has been frequently reviewed by neurology, but his condition has not improved. The patient suffers from severe shooting pain affecting the right side of his lower face, with each episode lasting about an hour. The frequency of attacks has increased over time, and he now experiences four to five episodes per week. The patient’s symptoms have significantly impacted his quality of life, and he rarely leaves his house due to fear of an attack.
Carbamazepine was initially prescribed four years ago, which provided some relief, but the patient was intolerant due to drowsiness. Subsequent trials of oxcarbazepine, lamotrigine, and baclofen did not provide lasting relief. The patient was recently diagnosed with depression and started on sertraline. He also has type 2 diabetes, which is managed with diet and metformin 500 mg TDS. The patient has been unable to work as a school-teacher for the past two years due to his symptoms. Although he was previously hesitant to consider surgical intervention, he is now willing to try any options that could improve his symptoms.
MRI brain with/without contrast showed no evidence of inflammation, space-occupying lesion, extra-cranial mass along the course of trigeminal nerves, widespread demyelination plaque, or previous infarction. There was also no abnormal enhancement of the trigeminal nerves.
What is the most appropriate surgical intervention for this patient?
A right-handed smoker in his 60s is referred by his general practitioner for assessment of likely stroke. His wife reports a sudden onset of left-sided weakness and bumping into objects on the left.
Upon examination, you observe left-sided motor weakness, sensory inattention, and a possible field defect. However, the patient’s restlessness prevents you from determining the field defect accurately. You admit him to the hospital and arrange for brain imaging. While waiting for imaging, the neuro-ophthalmology team evaluates him and formally plots his visual fields.
What type of visual field defect do you anticipate?
You assess a 30-year-old motorcyclist who was in a motor vehicle accident and presents with weakness in the left leg. The admitting registrar suspects Brown-Séquard syndrome. During your examination, which of the following clinical signs on the right lower limb would you expect to observe?