A new case-- time to put your thinking caps on

Dear Bloggers

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

The patient was a 47 year old female working for a busy fashion design company. She developed unsteadiness when walking at work. She was uncertain whether it was of sudden onset but she remembered she did not have this problem when on the bus and then train that she took daily to her job.The unsteadiness was not associated with dizziness, new visual disturbance, nausea, vomiting or hearing loss and she denied motor symptoms. She denied vertigo and dizziness on standing.

She did however admit to the following symptoms including:

1) Diplopia- a two year history that had not got worse and was corrected by her prescription spectacles; this occurred mainly when she looked upwards.

2) Numbness of her arms and legs- this had occurred several days before the onset of the unsteadiness and was throughout the entire length of her limbs. She did not have any facial numbness according to her account.

3) Slurred speech- this occurred around the same time as the onset of unsteadiness.

Previous medical history included

• Viral meningoencephalitis (20 years before)
• Post-meningitis seizures treated with medication; no seizures for many years.
• Glaucoma

Medications included

• Phenobarbital
• Sodium valproate
• Phenytoin
• Flunitrazepam
• Metoclopramide

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.

Pertinent Negatives

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

On examination

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.

CNS

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.

PNS

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?