You review a 42-year-old man who plays Sunday league rugby for his local club. He reports experiencing numbness in his left middle and index fingers. Upon examination, you note weakness of finger extensors and an absent triceps reflex. What is the most likely location of the lesion?
A 40 year-old man presents with an acute onset of weakness in the left face, arm, and leg, which has not resolved. On examination, there is upper motor neuron facial weakness on the left, with dense weakness of the left arm and leg. There is no evidence of sensory neglect, hemianopia, or dysphasia.
His past medical history includes migraine with visual aura, for which he takes propranolol and sumatriptan. His last migraine attack was a month ago. He has suffered two transient ischaemic attacks in the last year, and now also takes clopidogrel. His father also suffered from migraine with aura and died in his 50s after suffering a series of strokes.
Plain computed tomography shows multiple round lesions in the white matter, which appear the same density as cerebrospinal fluid. Magnetic resonance imaging shows scattered well-circumscribed lesions in the subcortical white matter which appear hypointense on T1 and hyperintense on T2-weighted sequences. On DWI (diffusion-weighted imaging) there is a hyperintense lesion in the right internal capsule, with a corresponding hypointense area on the ADC (apparent diffusion coefficient) map.
What is the most likely underlying diagnosis?
A 55-year-old unemployed man presented with a 7-month history of progressive speech difficulty. He had appeared depressed over the same period after losing two jobs in the last year. His wife commented that he had lost all motivation and spent most of the day at home. His appetite had changed and he had become very fond of sweet foods, with his weight increasing by 2 stones in the last year. Higher mental function testing revealed problems with naming and in tasks requiring planning.
Examination of the cranial nerves and limbs was normal.
What is the most likely diagnosis?
A 32-year-old man presents to the Psychiatry Hospital with a 4-month history of insomnia, weight loss, depression, forgetfulness, and pins-and-needles sensation in his limbs. He was prescribed amitriptyline, but after 8 weeks, he began experiencing increased forgetfulness, unsteadiness, and intermittent incontinence. A medical registrar was consulted and found the patient disorientated to place and person, with myoclonic jerks, restricted upward gaze, limb and gait ataxia, and flexor plantar reflexes. A CT scan of the head was normal, but an EEG showed diffuse slowing. Further investigations revealed a positive anti-thyroid peroxidase antibody and elevated TSH levels. What is the most likely diagnosis?
A 50-year-old female presents with bilateral tingling sensation in her medial one and half digits at night, along with clawing of her 4th and 5th digits. She is concerned about the cosmetic aspect of her condition. Additionally, she has been experiencing left-sided foot drop for the past 8 months. Her medical history includes type 2 diabetes mellitus, for which she takes metformin 850mg TDS, but admits to occasional poor compliance. Her last HbA1c was 53 mmol/mol. She has had multiple surgeries on her feet during childhood, but does not remember the details. She was adopted and has no knowledge of her birth family history. On examination, she has a left common peroneal palsy, thin calves bilaterally, and loss of sensation in bilateral ulnar nerve territories. What is the underlying diagnosis for her symptoms of paraesthesia and foot drop?
A 70-year-old man presents to the clinic after experiencing three episodes of transient right monocular visual loss. He describes the visual loss as a curtain descending down on the right eye, lasting several minutes and resolving. He also reports recent headaches. He denies any limb weakness and has been in good health prior to these events.
The patient has a medical history of hypertension and takes regular bendroflumethiazide. He is a heavy smoker, consuming 30 cigarettes per day, and does not drink alcohol. On examination, he appears plethoric with a blood pressure of 140/80 mmHg, pulse of 88 beats per minute and regular rhythm. Oxygen saturation is 99% on room air.
An audible bruit is heard over the right carotid artery, and he has pulsatile non-tender temporal arteries. A mass is palpated in the left upper quadrant of his abdomen. His heart sounds are normal, and his chest is clear. A full neurological examination, including fundoscopy, is entirely normal.
Investigations reveal a high haemoglobin level, elevated white cell count and platelets, and increased haematocrit and red cell count. Doppler scanning of the carotid arteries shows 100% stenosis of the left internal carotid artery and 60% stenosis of the right internal carotid artery. He is started on aspirin 300 mg orally for two weeks.
What further actions would you take for this patient?
A 35-year-old man comes to the Neurology Clinic for evaluation. He has been experiencing severe headaches every afternoon and evening, which are located in the frontal, like a band around his head and last for 1-2 hours each time. He has been taking 2g of Acetaminophen and 30 mg of Codeine phosphate four times a day, and has attempted to stop taking the medication, but the headaches return when he does. His neurological examination is normal, and his CT and MRI scans, as well as a variety of screening blood tests, have all come back normal.
What is the most appropriate next step?
A 65-year-old retiree presents with difficulty recalling recent events. He reports consuming six glasses of wine daily. He shares a far-fetched tale about his day’s events. During the central nervous system (CNS) evaluation, you observe bilateral internuclear ophthalmoplegia. He has slight anemia, with an MCV of 110 fl, and a random blood glucose level of 4.2 mmol/l. What is the preferred treatment?
A 70 year-old man experienced a sudden onset of painless visual loss in his right eye for 1 minute. He described it as a curtain descending across his vision. The patient has a history of hypertension. An ECG revealed sinus rhythm, while a Doppler of his carotids showed a 90% stenosis in the right external carotid artery and a 40% stenosis in the right internal carotid artery. What is the best course of treatment for this patient?
A 65-year-old man has been diagnosed with Alzheimer’s disease and is being seen in a memory clinic. Over the past three months, his cognitive function has declined, and his wife reports that he is struggling with basic tasks such as dressing and eating. She has also noticed a decrease in speech, but his personality remains intact. He has experienced nausea and diarrhea. He has been taking donepezil 10 mg/day for six months, with initial improvement for the first three months. He has no other medical history and takes no other regular medication. His wife is his primary caregiver.
During the examination, the patient had a normal demeanor and interacted well. He scored 11/30 on the mini-mental state examination, with deficiencies in recall, visuospatial tasks, language, and executive function. He exhibited marked dyspraxia on testing alternating hand movements. Examination of the cranial nerves appeared normal, and examination of the peripheral nervous system revealed brisk lower limb reflexes with extensor plantar responses.
What would be the appropriate management plan for this patient?