Today I have another great case for you supplied by a distant hospital in Japan. The case has been anonymised to safeguard patient confidentiality.
Presenting complaint: unsteadiness when walking
Previous medical history included
- Viral meningoencephalitis (20 years before)
- Post-meningitis seizures treated with medication; no seizures for many years.
- Sodium valproate
No known drug allergies (NKDA)
She was otherwise fit and healthy and was a hard working mother of two children and was happily married. She was fully independent and was a non-drinker and had never smoked. There was no family history of cardiac, respiratory, abdominal or CNS disease.
She denied the following:
GEN- no fever, no sweats, noshakes/chills, no constitutional symptons
HEAD- no sinus pain, no otalgia and no throat pain.
CVS- no palpitiations, no chest pain, no dyspnoea
RESP- no recent cold, no cough, no sputum, no haemoptysis
ABDO- no nausea, no vomiting, no jaundice, no pain, no constipation or diarrhea. Normal appetite and no weight loss.
MUSC- no weakness, no muscle pain, no joint pains or swelling
UROGEN- normal menstrual periods, no menorrhagic, no abnormal vaginal discharge, no urethral pain, no urgency, no frequency and no haematuria. No new sexual partner—not using barrier contraception.
CNS- no sudden onset headache, no hx of migraines, no blurred vision, no loss of vision, no swallowing problem, no hearing disturbance, no facial numbness.
PNS- no falls, no collapse, no uni- / bi-lateral weakness, no loss of bladder or bowel control. No back pain.
Endocrine- No polyuria, no polydipsia, no disturbance of concentration, no increased or decreased appetitie, no lactation, no recent increase or decrease in weight / size of hands or feet, no Hx of hypertension.
Skin- she denied any new skin problems
The patient was alert and looked otherwise well. She was afebrile, BP 120/80mmHg, Pulse 80/min regular, Resp rate 14/min regular, O2 sats 98% breathing ambient room air.
General- pinky-red cheeks, coarse skin and evidence of alopecia.
No jaundice, anaemia, clubbing, cyanosis, oedema or lymphadenopathy (JACCOL)
CVS- Hands warm and well perfused. Pulse good volume. JVP not elevated. Heart sounds 1 & 2 normal with no added sounds or murmurs. No carotid bruits. No peripheral oedema.
RESP- Trachea central and no tracheal tug. Expansion normal. Percussion note normal. Normal vesicular breath sounds.
ABDO- Soft, flat, non-tender, no masses. Bowel sounds normal. Genital and rectal examinations not performed.
Breast exam- normal.
I normal sense of smell
II normal visual fields. Pupils equal and reactive to light and consensual reflex normal.
III / IV / VI – Normal range of movement but Nystagmus bilaterally (mild) and some vertical nystagmus on vertical gaze.
V- motor and sensory normal.
VII / VIII - normal
IX / X / XI / XII - individual nerve testing normal.
Mild slurring of speech noticed.
Fine resting tremor- not ‘pill rolling’ type.
Tone- normal throughout
Power- normal throughout
Reflexes- absent throughout
Sensation- mildly reduced light touch throughout; other modalities not tested
Coordination- finger to nose test positive bilaterally. Dysdiadochokinesis positive bilaterally. Heel to shin test positive R>L.
Babinski sign negative bilaterally
Gait- wide based, staggering in nature (ataxic) and heel to toe test positive.
Question 1: Please make a problem list soley from the history and physical examination findings.
Question 2: What other specific question(s) would you like to learn from the history that might help you with this diagnosis?
Question 3: What particular feature of the oral examination might give you a further clue regarding the cause of this problem?
Question 4: What is the diagnosis?
Question 5: Which one laboratory test would give you the diagnosis?