A 45-year-old office worker presented with a 9-month history of gradual weakness in their left hand and a 4-month history of similar weakness in their right hand. They had no significant medical history. On examination, there were fasciculations in both biceps muscles with increased tone in both arms, weakness of intrinsic hand muscles bilaterally, and brisk upper limb reflexes. Coordination and sensory examinations were unremarkable. What is the most probable diagnosis?
A 25-year old woman, who has been out of work since dropping out of college early, arrived at the Emergency Department with a sudden onset of left-sided hemiparesis. Her father mentioned that she had been hospitalized for chest pain 4 years ago, but he did not have any further information about the admission. She occasionally smokes cigarettes when she can afford them.
During the examination, she had a flushed face and livedo reticularis on her thighs. She was 1.7 m tall and had scoliosis. Her blood pressure and heart sounds were normal. Her Mini-mental scale score was 26/30. She had a slight left-sided facial palsy and pyramidal weakness in her left limbs. Her speech and sensory system were normal.
What is the most probable underlying diagnosis?
A 32-year-old man presents to the Emergency department with a three-day history of paraesthesia in his feet and hands. He has also noticed weakness in his thighs, particularly when walking down stairs, and weakness affecting his shoulders. Prior to this, he had been well, except for a mild case of gastroenteritis after eating Chinese food. On examination, he appears anxious, but cranial nerve examination and fundoscopy are normal. Upper limb examination reveals reduced tone and absent reflexes bilaterally at both wrists. Lower limb examination shows 2/5 power, absent reflexes, and reduced sensation affecting both feet. A lumbar puncture is performed, yielding the following results: opening pressure 14 cmH2O (5-18), CSF protein 0.40 g/L (0.15-0.45), CSF white cell count 4 cells per ml (<5 cells), CSF red cell count 2 cells per ml (<5 cells), and negative CSF oligoclonal bands. What is the diagnosis for this patient?
A 54-year-old woman presents to the Emergency department with severe back pain and subsequent weakness and paraesthesia affecting both legs. She is unable to urinate and her leg weakness worsens. She recently returned from a holiday in Tenerife and has a medical history of diabetes, hypertension, and hypercholesterolaemia. She drinks 15 units of alcohol per week but does not smoke. On examination, she appears distressed with a palpable bladder and neurological deficits in the lower limbs. A lumbar puncture reveals normal CSF results. What is the most likely diagnosis?
A 42-year-old man had surgery to remove a tumor from his right lung three years ago. He received postoperative radiation therapy of 5000 cGy. His primary care physician has referred him for assessment of a painful right arm with weakness.
During the examination at the clinic, the patient appears alert but apprehensive. The right palpebral fissure is slightly smaller than the left, but eye movements are normal. The right pupil is smaller than the left. Swallowing and speech are normal, as is facial expression. The small muscles of the right hand are atrophied and weak, with clawing affecting the right ring and little fingers. There is decreased sensitivity to pinprick on the ulnar border of the right hand and forearm.
What is the most probable underlying diagnosis?
A 50-year-old man presents to his GP with a complaint of episodic vertigo that has been occurring for the past two weeks. He reports that the vertigo is particularly noticeable at night when he is trying to turn over in bed. He denies any history of nausea, vomiting, tinnitus, hearing problems, diplopia, or limb weakness. He recently had a cold and has been feeling under the weather in the last week, but otherwise has no other symptoms. He has a past medical history of epilepsy and takes regular carbamazepine. He is a non-smoker and drinks eight units of alcohol per week.
On examination, his vital signs are normal. The external auditory canal and tympanic membrane appear intact in both ears. Cranial nerve examination reveals asymmetric horizontal nystagmus with a rotational component, but ocular movements and pupillary responses are normal. The rest of the cranial nerves, including Weber and Rinne’s tests, are normal. Tone, power, reflexes, sensation, and coordination are normal in both the upper and lower limbs.
The Dix-Hallpike manoeuvre elicits a latent period to onset of nystagmus of 15 seconds, associated with vertigo and nausea. There is reversal of nystagmus on returning to an upright position. Fatiguing of symptoms and signs is observed on repeating the test. A contrast-enhanced CT scan of the brain is normal.
What is the likely cause of this patient’s vertigo?
You are asked to evaluate a 36-year-old man who has been experiencing progressive limb weakness over the past 48 hours. The patient reports being an intravenous drug user and having a groin abscess drained recently. He also mentions having a stomach illness two weeks ago, but those symptoms have since resolved. During the physical examination, you observe flaccid weakness in all four limbs and absent reflexes in both lower limbs. The cranial nerves examination is unremarkable. What is the most likely diagnosis based on these findings?
A 42-year-old Nigerian man presents with fatigue. He has been exhibiting strange behavior and psychotic symptoms for the past year and is currently being treated with risperidone. He was diagnosed with HIV-1 infection five years ago but has not been following up with treatment.
Upon physical examination, no abnormalities were found. His CD4 count is 20 × 106/l and HIV viral load is > 500,000 copies/ml. Antiretroviral therapy is initiated and the patient is discharged.
One month later, the patient returns with confusion. He is afebrile upon admission and disoriented in time and place but not in person. His CD4 count is now 50 × 106/l and HIV viral load is 503 copies/ml.
Further investigations reveal a hemoglobin level of 95 g/l, WCC of 4.8 × 109/l, neutrophils at 70%, lymphocytes at 20%, and platelets at 400 × 109/l. A CT scan of the brain shows multiple low-density lesions in the right hemisphere.
Cerebrospinal fluid analysis shows a white cell count of 150/ml, glucose level of 3.5 mmol/l, protein level of 0.6 mg/dl, and negative results for cryptococcal antigen, toxoplasmosis PCR, and India ink stain.
Four days later, the patient develops left-sided weakness. A magnetic resonance imaging scan with contrast shows diffuse enhancement of the lesions.
What is the most likely diagnosis?
A 12-year-old boy is brought by his father to the clinic for evaluation of his neurological status. He has been experiencing a decline in academic performance for the past 4 months, and has been recently observed by his teacher to have outbursts of anger in the classroom.
His father is concerned that in the early morning his son experiences sudden contractions of his shoulder muscles and complains of blurry vision. This has been happening for the past 2 weeks. On the morning of his visit, he had a seizure followed by loss of consciousness. In his early childhood, he had a rash illness from which he recovered without any complications.
During the examination, the boy is lethargic and uncooperative. Cranial nerves appear normal. He experiences sudden contractions involving all four limbs. Tendon reflexes are brisk with bilateral Babinski’s sign. He has a wide-based gait and is unable to walk in a straight line. Blood pressure is noted at 110/75 mmHg, with pulse 90 bpm and regular. General physical review is unremarkable, as are routine blood tests and a chest X-ray.
What is the most likely diagnosis?
A 25-year-old Japanese woman was brought to the Emergency Room on a stretcher as she was found lying on the floor of her apartment unable to move by her roommate. She had participated in a 5K race at a local park, the day before and had eaten a full chocolate cake before going to bed. She got up around 4 am to get a glass of water and noticed weakness in her limbs. She could hardly hold the glass and finally fell on the kitchen floor. Over the past few weeks, she has suffered from increasing heart palpitations and stress related to her upcoming exams.
Upon examination, she was of average build and anxious. She gave a clear account of the progression of her illness. Pulse was 110/min and irregularly irregular. Blood pressure was 130/90 mmHg. Cranial nerves were normal. Neck muscle power was 4/5. Shoulder girdle, truncal and pelvic girdle muscles 3/5. Tendon reflexes were decreased and plantar were absent. Sensation was intact.
What is the most probable diagnosis?