Nervous System & Special Senses


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M67_F1.jpg"}},{"insert":"\n\n"},{"insert":"\u0022...and I have discharged her back to your excellent care.\u0022 You finish dictating a letter for your patient, who has made an excellent recovery six months after a stroke.\nA quick glance at the clinic list shows that you are just halfway through the patients for the day. You gulp down the lukewarm coffee on your desk and prepare for the next patient.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M67_F2.jpg"}},{"insert":"\n\n"},{"insert":"You are introduced to Grant, a 55-year-old farmer, and his wife Pammy.\n\nGrant complains of an intermittent left hand tremor that has gradually worsened over the past year, along with some mild discomfort in his left arm.\n\n\u0022It\u0027s been getting worse over the past year. I notice it most when I\u0027m sitting in the chair, but it seems to get better when I do something with the arm! It\u0027s probably just old age.\u0022\n\nAs he tells you this you notice Pammy rolling her eyes: \u0022Doctor, he\u0027s only 55 and you should see the way his arm shakes. It\u0027s just like Elvis Presley!\u0022\n\nYou smile and continue with your history taking.\n"}]}


{"ops":[{"insert":"Grant denies any falls, but admits to some slowing of his walking. He has also found it difficult to get up from his chair and roll over in bed.\n\nOn further questioning he denies any depressive symptoms, falls, hallucinations or changes in cognition. This is further corroborated by Pammy. She also denies any sleep disturbances overnight.\n\nHe is otherwise healthy and has no significant past medical history, and is not on any regular medications. He lives with his wife and is usually fiercely independent and mobilizes without aid, but has had to start using a walking stick intermittently. This has impacted significantly on his work.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M67_F4.jpg"}},{"insert":"\n\n"},{"insert":"You proceed to the physical examination. On general inspection, you note hypomymia and a resting tremor in his left hand which resolves on reaching for a cup; and temporarily with a hand outstretched. His vital signs are within normal limits and there is no postural hypotension.\n\nOn gait examination he has trouble rising from his chair and you note some difficulty in initiating his gait. He has a slow, shuffling gait and a stooped posture, as well as reduced left arm swing. He takes multiple steps to recover from being pulled backwards.\n\nThere is cogwheel rigidity in the left upper limb. On rapid finger and toe tapping you note reduced amplitude with decrementing speed. You note micrographia on asking him to write a sentence. Power and sensation is normal and there are no cerebellar signs.\n\nThere is no gaze restriction, axial rigidity or cranial nerve abnormalities. On repeated tapping of the forehead, Grant continues to blink. There is mild hypophonia.\n\nYou perform a mini-mental state exam. Grant scores 30\/30.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M67_F5.jpg"}},{"insert":"\n\n"},{"insert":"Having completed your physical exam, you sit down and ponder the possibilities.\n\n\u0022So what do you think Grant has?\u0022 asks Pammy anxiously.\n\nWhat do you think he has?\n"}]}
1. Essential tremor
2. Parkinson's disease
3. Lewy body disease