Vignettes Session 6 new
R. Wiley, MD, PhD
873-7510
“ronald.wiley@vanderbilt.edu”
79 y/o RH WF presents to ED with left sided twitching. Two months ago, she began to
notice that her left leg would twitch w/ episodes lasting 1-3 min. One month ago, her
left arm would twitch also and she has also noted progressive weakness of the left side
of her body. Today, her left hand became almost completely limp. She has been losing
weight despite good appetite, and she has developed a cough.
PMHx and FamHx: negative
Meds: vitamins
Vitals: P 80 BP 110/70 R 20 T 37
General: cachexia, decreased breath sounds bilaterally, dullness at L lung base
Neurological: intact except –
Sensory – decreased proprioception on L hand
Motor – flaccid L hemiparesis
Reflexes – extensor plantar on L
52 y/o M w/ 8-year history of colon cancer on chemo until 6 months ago is admitted
for confusion and lethargy. For past 2 months, he has had poor appetite and
intermittent vomiting. Two weeks ago, he had 2 generalized seizures, and was started
on phenytoin. Since then, he has become progressively more confused without
recurrent seizure.
FamHx and SocHx are not contributory except pt does admit to drinking Etoh but can’t
exactly quantify.
Vitals: P 100 BP 110/70 R 20 T 37
General: skin and sclerae icteric, nodular liver palpable 3 cm below costal margin
Neurological:
MS – oriented to self, recalls 0/3 at 5 min, present President “that blond woman, I
can’t remember her name”, slow but accurate calculation
Gait – refused as he becomes lightheaded
Coord – mild intention tremor on FNF
CN – intact except - nystagmus in direction of horizontal gaze
Sensory – decreased vibration, pain and light touch in stocking distribution
Reflexes – trace in UE, absent in LE
47 y/o RH WF with 2d Hx of word finding problems and memory as well as concentration
difficulty. She reports a 1.5yr of BLE numbness and gait unsteadiness, worse in the dark.
These sx were of gradual onset. For the last 6mo she has needed to use a walker to get
around. She also has shooting pains in her neck and back and both arms.
FH is negative.
Meds: She has only used occasional NSAIDs for back pain.
Soc Hx: She smokes 1/2ppd, no drugs and social etoh. She was single and worked as a security
dispatcher.
General: T-98.2, HR-68, B/P-110/60, R-18, P/E - unremarkable
Neurological:
MS - alert, oriented, fluent, conversant, 26/30 on MMSE missed 2/3 on recall and couldn’t do
serial 7s
Gait - Slow, cautious, unsteady wide-based gait, with each step, the foot was thrust outwards
and made an audible slapping sound as it struck the floor.
Coordination - nl FNF and HTS
CN - 2-12 intact
Sensory - Diminished pinprick sensation in a stocking-and-glove distribution (to wrist and to
ankles). Vibration and proprioception sense loss in both lower extremities from the waist
down. Romberg test showed patient able to stand with feet together with eyes open, but fell
with eyes closed.
Motor - nl bulk, increased tone in BLE, no abnl movts, 5/5 in all ext bilat except bilat iliopsoas
4/5
Reflexes - DTRs 3+ in all bilat except 2+ in ankles, toes upgoing bilat
44y/o RH WF with PMHx of HTN presented to the ED with a history of
3d of HA and gait unsteadiness as well as blindness over several
hours, denies other symptoms.
Meds: She doesn’t know what medications she takes.
Soc Hx: Denies substances abuse
FamHx: non-contributory
General: HR 102 BP: 186/96, afebrile, RR 14 unlab; general exam benign
Neurological:
MS - anxious, alert and oriented, no dysphasia; able to give a detailed hx
Gait - ataxic gait, wide based, no falling to any one side; not able to
tandem/heel or toe walk due to unsteadiness
Coordination - FNF and HTS no dysmetria
CN – vision limited to light perception only; PERRLA, fundi unremarkable
Sensory - intact to all modalities
Motor – normal
Reflexes - 2+ and symmetric bilat; toes down
41 y/o WM, previously in excellent health, brought to the ED confused, sometimes
agitated. He is a wealthy businessman from Texas visiting NYC for meetings. He was
last seen by his colleagues leaving dinner the previous evening for some local
entertainment. The following morning, he was found in the wrong hotel room
wandering in a confused state.
Meds: none
FH/PMH and SH: not obtainable.
General: P 120 BP 120/80 R 14 T 39°C, skin flushed and dry
Neurological:
MS – delirious, appears to be hallucinating, no meaningful response to
commands
CN – pupils 7 mm bilaterally, minimally reactive
DTR – hyperreflexic throughout