Nervous System & Special Senses


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M65_F1.jpg"}},{"insert":"\n\n"},{"insert":"It has been a hectic day for you, the neurology resident. You have run multiple stroke calls, seen thirty patients on the ward and reviewed consults all over the hospital. Just to top it off, you have been called to see a new patient in the emergency department at 4.55 PM.\n\nYou enter the emergency department cubicle, hoping this will be a simple case and reminding yourself you chose this career...\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M65_F2.jpg"}},{"insert":"\n\n"},{"insert":"Your next patient is James, a 54-year-old truck driver who presents with weakness in his legs. He reports having been well until 3 weeks ago, when he had an episode of diarrhea lasting for 5 days. This self-resolved, and he had been well until 3 days ago, when he started to notice difficulty walking which has gradually worsened. He also complains of some numbness in his legs.\n\n\u0022It\u0027s ridiculous, doc - I haven\u0027t even had the strength to push on the pedals at work! I\u0027ve had to take yesterday off, but I really need to get back to work.\u0022 As James reports this, alarm bells start going off in your head. You hasten to ask him further questions.\n"}]}


{"ops":[{"insert":"James denies any back pain, fevers or rigors. He denies any trouble with his bowels or bladder and has had no recent traumatic injuries.\n\nHe is otherwise healthy and has no significant past medical history, and is not on any regular medications.\n\nJames lives with his wife and two sons and usually mobilises without aid. He is a non-smoker and a non-drinker.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M65_F4.jpg"}},{"insert":"\n\n"},{"insert":"You proceed to the physical examination.\n\nHis heart rate is 80 bpm, blood pressure is 130\/80 mmHg, respiratory rate is 16\/min and oxygen saturation is 99% on room air. He is afebrile, comfortable and not in pain.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M65_F5.jpg"}},{"insert":"\n\n"},{"insert":"You proceed with a focused neurological examination.\n\nOn gait examination James is unable to walk on his heels or toes, and nearly falls over.\n\nCranial nerve examination reveals bilateral weakness of the facial nerve. Upper limb neurological exam is normal.\n\nOn lower limb neurological testing, there are no fasciculations or wasting. Tone is reduced bilaterally. Power is reduced distally in a symmetrical pattern with grade 3\/5 ankle movements. Reflexes are absent. Sensation shows patchy sensory loss in all domains in both lower limbs but no sensory level. Coordination is normal.\n\nAnal tone is normal with normal perianal sensation.\n"}]}


{"ops":[{"insert":"At this point, your attending pops into the cubicle and listens patiently to you presenting the patient. At the end of it, he smiles and asks, \u0022what is the most likely diagnosis?\u0022\n\nHow will you answer?\n"}]}
1. Guillain-Barre syndrome
2. Transverse myelitis
3. Spinal cord compression