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Erik Administrator
Join Date: Jan 2006
Posts: 168
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Neurology Case Challenge 2: Strange behaviour and Itching
The patient is a fifty year-old right-handed Asian man brought to the E.R. by his family after another in a string of recent falls.
The patient was apparently healthy until six months prior to admission when he developed generalized pruritis. A local physician diagnosed "allergies" and prescribed "itching medicine". This treatment was not effective, but the patient did not seek further medical aid. Around this time, his family noticed that something was wrong with the patient's left arm and leg. They felt that he had become clumsy and noticed that he began to fall and injure himself. The majority of these falls resulted from the patient's apparent misjudgments of distance - he would run into walls or doorways, always with the left side of his body. Four months ago he was involved in a car accident when he did not see another car approaching from the left side. While he was somewhat perplexed by his numerous recent injuries and left-sided clumsiness, the patient felt that he was fine and his family was over-reacting. Over the ensuing six months the falls became increasingly more frequent, prompting the current visit.
His family also noted other strange behaviors over the course of the past six months. While previously well-kept, the patient now had difficulty dressing himself and frequently forgot to shave and bathe. In addition, he seemed more absent-minded, forgetting the names of people he had known for some time and misplacing his keys. When asked what was wrong with him, the patient only replied, "I itch all over". Gathering further information required directed questions, which the patient answered truthfully, though slowly. When directly asked, he admitted to weakness on the left side of his body, mild memory problems, and frequent falls; however, he was not particularly bothered by this. He was most concerned with his constant itching.
He denies headache, numbness, tingling, weight loss, dysarthria, dysphagia, diplopia, vertigo, arthralgias, hematuria, dyspnea, chest pain, photosensitivity, fever, chills, and night sweats. He also denies any ill contacts or other ill family members.
Past Medical History:
There is no history of significant previous illnesses.
Family History:
The patient is unaware of any illnesses that run in the family.
Social History:
He lives with his wife and two daughters, aged six years and two weeks. He smokes one pack of cigarettes a day and drinks 3-4 beers a day. He moved to the United States from Vietnam in the late 1970s. He currently works as an air conditioning repairman. He traveled to Southeast Asia six years ago, but denies any other recent travel. He denies any high-risk sexual behavior or intravenous drug use.
Physical Examination
Vital signs:
B.P. 116/74; pulse rate 82 bpm; temperature 99.2 F; respirations 18.
General:
The patient was a thin Asian male appearing older than his stated age, in no acute distress.
HEENT:
The head is normocephalic and atraumatic. The oropharynx is clear and moist without lesions. The sclerae are anicteric and conjunctivae are pink. There is no cervical or post-auricular lymphadenopathy.
Cardiovascular:
The heart shows a regular rate and rhythm without rubs, gallops, or murmurs. The peripheral pulses are all within normal limits.
Heart:
RRR with no murmurs, rubs, or gallops.
Chest:
Lungs are clear to auscultation and percussion without rales, rhonchi, or wheezes.
Abdomen:
Bowel sounds are present and within normal limits. There is no tenderness to palpation and no masses are felt. There is no hepatosplenomegaly.
Skin:
Examination of the back shows pitted scars and follicular, excoriated, crusty papules. The right lower buttock shows linear excoriations with crusting. The trunk, arms, upper thighs and pubic area are covered with scattered, excoriated, crusty papules. There are no lesions on the wrists, palms, soles, ankles, or periumbilical area. No burrows are seen.
Neurological Examination
Mental status:
Behavioral Observations:
The patient was unkempt, unshaved, with uncombed hair and dirty clothes. His movements and thinking were somewhat slowed. He appeared apathetic.
Affect:
Blunted
Attention:
Basically intact. The patient was able to register three objects and perform serial 7s. He made one error in spelling WORLD backwards.
Language:
Fluent with intact comprehension, naming, reading, writing, and repetition.
Prosody:
Not formally tested.
Memory:
Short-term memory was impaired, as the patient was unable to remember the month, day, year, and one of three objects at five minutes. With cues the patient was able to remember this information. Long-term memory was grossly unaffected.
Constructional ability:
Markedly impaired - the patient neglected the left half of the drawing.
Abstract thinking:
Not formally tested.
Calculations:
Grossly intact.
Praxis:
The patient demonstrated a gross dressing apraxia - he was able to dress his right side but could not reliably place clothes on the left side of his body. In addition, the patient demonstrated ideomotor apraxias to throwing a ball, flipping a coin, and brushing his teeth. When asked to perform these tasks he merely fumbled about.
Cranial nerve function:
II Pupils are equal, round, and reactive to light. Visual fields show a left homonymous hemianopsia with macular splitting. Fundoscopic exam is within normal limits. Visual acuity was not tested.
III,IV,VI Extraocular movements are intact without diplopia or nystagmus. There is no ptosis. OKN testing is markedly diminished on moving the OKN strip to the right side.
V Sensation is intact in all three divisions to light touch and temperature sense. Temporalis and masseter show normal strength.
VII The left nasolabial fold is slightly decreased; otherwise strength is symmetrical on the two sides of the face.
VIII Hearing is grossly intact to bilateral finger rub. Weber does not lateralize and air conduction is greater than bone conduction bilaterally.
IX, X The palate elevates in the midline. There is a normal gag.
XI Sternocleidomastoid and trapezius strength is intact bilaterally.
XII The tongue protrudes in the midline without atrophy or fibrillations.
Motor examination:
Tone was slightly increased on the left side. Muscle bulk was normal throughout without atrophy or fasciculations. There was no cogwheel rigidity and no tremor was present.
Strength testing of the upper and lower extremeties were all 5/5 with exception to Left hand instrinsic, finger flexors, and wrist extensors (4/5) and Left knee flexor and extensor (4/5) and ankle extensor (2+/5):
Sensory Examination:
There was normal vibration, pinprick, temperature, and proprioception sense throughout. Graphaesthesia and stereognosis were intact. On double-simultaneous stimulation, the patient extinguished the stimulus on the left hand. The Hand-face test was not performed.
Reflexes: Hyporeflexic in right brachioradialis and patellar (2/3)
Bilateral crossed adductors were present at the knees. Babinski's were present bilaterally. There was a Hoffman's sign on the left. There was no jaw jerk.
Cerebeullum:
There was no finger to nose dysmetria. There was no dysmetria on heel to shin testing. Rapid alternating movements were slow but showed no dysdiadochokinesia. There was no loss of check.
Gait:
The patient showed a mild left hemiparetic gait with a prominent left foot drop. Arm swing was decreased on the left side.
What would you do next? Which tests to order? What is your differential?
This case has been adapted from the Baylor College of Medicine Dept of Neurology.
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