1. R. Wiley, MD, PhD 873-7510 “ronald.wiley@vanderbilt.edu”
Vignettes Session 7 new
R. Wiley, MD, PhD

2. PMHx and FamHx: negative Meds: vitamins
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° C
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
Focal seizures in brain metastases – Wiley Case 17. Abnormal CXR. Otherwise, primary tumor not known.

3. Gait – refused as he becomes lightheaded
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 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
Wernicke and Korsakoff –Wiley Case 9

4. Meds: She has only used occasional NSAIDs for back pain.
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 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
Pernicious anemia; a careful assessment of the history reveals evidence for an encephalopathy, polyneuropathy, and a process involving the high cervical cord/lower medulla. A megaloblastic anemia was present which was consistent with (but not a necessary requirement of) the diagnosis of vitamin B12 deficiency. Obviously, a low serum B12 level in this clinical setting provided more supportive evidence. The abnormal Schilling test, which demonstrated a defect in absorption in cobalamin absorption that improved with addition of intrinsic factor, was diagnostic of pernicious anemia. She improved in 1month with IM B12 injections.

5. Meds: She doesn’t know what medications she takes.
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
HTN Encephalopathy case 1; f/u info for w/u - Magnetic resonance imaging (MRI) of the brain revealed abnormal signal bilaterally in the white matter of the posterior parietal and occipital region with involvement of both thalami, superior cerebellar peduncles, midbrain, and the left superior cerebellum (Fig. 1A). The patient was admitted with the diagnosis of PRES and BP was acutely controlled by intravenous hydralazine. Her neurologic symptoms improved gradually with complete recovery of vision and gait in 3 days. A follow-up visit at 6 weeks revealed complete neurologic recovery and vision of 20/25 bilaterally. The abnormal signals seen on MRI previously had resolved.

6. FH/PMH and SH: not obtainable.
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 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
Anticholinergic poisoning, treat with physostigmine – Wiley case 10