Minicases

Confusion/Memory Loss Key History

Must include history from family members or caregivers. Detailed time course of cognitive deficits (acute vs. chronic/gradual onset) Associated Sx (constitutional, incontinence, ataxia, hypothyroid Sx, depression) Screen for delirium (waxing/waning level of alertness) Falls Medications (*Recent med changes) Stroke Hx or other atherosclerotic vascular disease Syphilis and HIV RFs Alcohol use Vitamin B12 deficiency FHx of Alzheimers or other neuro disease

HA Key history

Onset (acute vs. chronic) Location (unilateral vs. BL) Quality (dull vs. stabbing) Intensity ("worst HA of your life") Duration Frequency Timing (disturb sleep) Sx prior to HA (aura) Ass. neuro findings (paresthesias, visual Sx, weakness, numbness, ataxia, photophobia, dizziness, neck stiffness) N/V, F/C, Wt. loss, night sweats Exacerbating factors (Stress, fatigue, menses, exercise, foods, alcohol) Alleviating factors (rest, meds) Pt and FHx of HA Hx of trauma

Depressed Mood key history?

Onset, duration, somatic Sx (fatigue, HA, abdominal distress) Sleep patterns Appetite and weight change Drug and alcohol use Life stresses Excessive guilt Suicidality Social Fx Environment Lack of pleasure/anhedonia decreased interest, energy, concentration Psychomotor agitation Retardation Mood changes Family Hx of mood disorders Prior episodes and meds

HA Key Physical Exam

-Inspection and palpation of entire H&N -ENT inspection -Complete Neuro Exam (MMSE, CNs, Motor, Proprioception, Reflexes, Sensory, Cerebellum, Meningeal signs)

Key history for Loss of vision?

Acute vs. Chronic Progression Ability to see light Associated Sx (eye pain, D/C, itching, tearing, photophobia, redness, HA, weakness, numbness, floaters, sparks) Hx of cardiac, rheumatic, thrombotic, autoimmune, or neuro disorders Jaw claudication Medications Trauma

35yo M presents with sudden onset severe HA, vomiting, confusion, left hemiplegia, and nuchal rigidity. DDx? W/U?

CT - head without contrast LP - opening pressure and CSF analysis CBC PT/PTT/INR Urine toxicology Digital Subtraction ANgiography (DSA) MRI - brain CT - angio

Confusion/Memory Loss Key Physical Exam findings

Complete neuro exam (Include MMSE and gait) General physical exam including ENT, heart, lungs, abdomen, and extremities

55yo M presents with a rapidly progressive change in mental status, inability to concentrate, and memory impairment for the past 2 months. His symptoms are associated with myoclonus, ataxia, and a startle response. DDx? W/U?

DDx: CJD Vascular dementia Lewy Body dementia Wernicke encephalopathy Normal Pressure Hydrocephalus Chronic subdural hematoma Intracranial neoplasm Depression Delerium B12 deficiency Neurosyphilis W/U: CBC Electrolytes, Calcium Serum B12 RPR/VDRL MRI - brain (preferred) CT - head EEG LP - CSF analysis Brain biopsy

68yo M w/ 2 mo history of crying spells, excessive sleep, poor hygeine, 15lb weight loss, al following his wife's death.He can enjoy time with his grandchildren and admits to thinking he has seen his dead wife in line at the supermarket or standing in the kitchen making dinner.

DDx: Normal bereavement Adjustment disorder with depressed mood Major depressive disorder Schizoaffective disorder Depressive disorder not otherwise specified W/U: TSH CBC Urine Tox Beck Depression Inventory PHQ-9 QIDS-SR16

18yo obese female presents with a daily pulsatile HA, vomiting, and blurred vision for the past 2-3 weeks. Taking OCPs. DDx? W/U?

DDx: Pseudotumor cerebri Migraine Tension HA Intracranial venous thrombosis Intracranial neoplasm Cluster HA Meningitis W/U: Urine - hCG LP (opening pressure and CSF analysis) Dilated fundoscopic exam Fundoscopic eye exam MRI - brain Visual field testing

81yo M presents with progressive confusion for the past several years accompanied by forgetfulness and clumsiness. He has a Hx of HTN, diabetes, and 2 strokes with residual left hemiparesis. His mental status exam has worsened after each stroke (stepwise decline in cognitive function) DDx? W/U?

DDx: Vascular (multi-infarct) dementia Alzheimer disease Normal Pressure Hydrocephalus Chronic subdural hematoma Intracranial neoplasm Depression B12 deficiency Neurosyphilis Hypothyroidism W/U: CBC VDRL/RPR Serum B12 TSH MRI - brain CT - head LP - CSF analysis

30yo F presents with 1 week of frontal HA, fever, and nasal D/C, the HA worsens when she bends forward. There is no pain on palpation of the frontal and maxillary sinuses. Hx of allergies. DDx? W/U?

DDx: Acute sinusitis Migraine Tension HA Cerebral abscess Meningitis Intracranial neoplasms W/U: CBC XR - sinuses CT - sinuses

84yo F brought in by son for forgetfulness (forgets phone numbers, loses her way back home) and difficulty performing some of her daily activities (bathing, dressing, managing, money, using phone). Problem has progressed over past few years. DDx? W/U?

DDx: Alzheimer disease Vascular dementia Depression Hypothyroidism Chronic subdural hematoma Nl Pressure Hydrocephalus Intracranial neoplasm B12 deficiency Neurosyphilis W/U: CBC VDRL/RPR Serum B12 TSH MRI-brain CT-head LP-CSF analysis

26yo F presents with a 6.5lb weight loss in the past 2mo, accompanied by early morning awakening, excessive guilt, and psychomotor retardation. She does not identify a trigger for the depressive episode but reports several weeks of increased energy, sexual promiscuity, irresponsible, spending and racing thoughts, approximately 6mo before her presentation. DDx? W/U?

DDx: BP I Disorder BP II Disorder Cyclothymic disorder Major depressive disorder Schizoaffective disorder W/U: Mood disorder Questionarre Urine Tox TSH CBC

26yo M presents with severe right temporal HA associated with ipsilateral rhinorrhea, eye tearing, and redness. Episodes have occurred at the same time every night for the past week and last for 45 minutes. DDx? W/U?

DDx: Cluster HA Migraine Trigeminal neuralgia Intracranial neoplasm Tension HA W/U: MRI - brain CT - head CBC ESR

21yo female presents w/ several episodes of throbbing left temporal pain that lasts for 2-3 hours. Before onset, she sees flashes of light in her right visual field and weakness and numbness on the R side of her body for a few minutes. Her HAs are often associated with N/V and she feels bothered by light. She has a FHx of migraines. DDx? Work up?

DDx: Hemiplegic migraine (Migraine with motor aura) Tension HA Cluster HA TIA Partial seizure Pseudotumor cerebri CNS vasculitis Focal seizure (occipitoparietal) Intracranial neoplasm W/U: MRI - brain CT - Head CBC ESR

70yo insulin dependent diabetic M presents with episodes of confusion, dizziness, palpitations, diaphoresis, and weakness. DDx? W/U?

DDx: Hypoglycemia TIA Arrhythmia Delerium Angina Medication induced W/U: Glucose CBC Electrolytes TSH CPK - MG, troponin ECHO EKG MRI - brain Carotid doppler U/S Urine Toxicoogy

42yo F presents with a 4 week history of excessive fatigue, insomnia, and anhedonia. She states that she thinks constantly about death. She has suffered five similar episodes in the past, the first in her 20s, and has made 2 previous suicide attempts. She further admits. to increased ETOH in the past. DDx? W/U?

DDx: Major depressive disorder Substance induced mood disorder Persistent depressive disorder (dysthymia) W/U: Beck Depression Inventory PHQ-9 QIDS-SR16 Blood alcohol level TSH CBC Urine tox

25yo army recruit presents with high fever, severe HA, confusion, photophobia, and nuchal rigidity. DDx? W/U?

DDx: Meningitis Subarachnoid hemorrhage Encephalitis Sinusitis Migraine Intracranial or epidural abscess W/U: LP - CSF analysis (cell count, protein, glucose, Gram stain, PCR for specific pathogens, Cx) Blood culture CBC CT - head MRI - brain PT/PTT/INR

72yo M presents with memory loss, gait disturbance, and urinary incontinence for the past 6 months. DDx? W/U?

DDx: Normal Pressure Hydrocephalus Alzheimer disease Vascular dementia Chronic subdural hematoma Intracranial neoplasm Depression B12 deficiency Neurosyphilis Hypothyroidism W/U: CT - head MRI - brain LP - opening pressure and CSF analysis Serum B12 VDRL/RPR TSH

73yo M presents with acute loss of vision in his left eye, palpitations, and SOB. He has a history of A-Fib and cataracts in his R eye. He has no eye pain, D/C, redness, or photophobia. He has not experienced HA, weakness, or numbness. DDx? W/U?

DDx: Retinal artery occlusion Retinal vein occlusion Acute angle closure glaucoma Retinal detachment Temporal arteritis W/U: Fluorescein angiogram ECHO Doppler U/S - carotid Intraocular tonometry ESR, CRP Temporal artery biopsy CBC

55yo F presents with gradual AMS and HA. 2 weeks ago she hit her head on the ground and experienced LOC for 2 minutes. DDx? W/U?

DDx: Subdural hematoma SIADH causing hyponatremia CJD Intracranial neoplasm CNS infxns W/U: CT - head CBC Electrolytes, TSH MRI - brain LP - CSF analysis

65yo F presents with a new onset severe intermittent right temporal HA, fever, blurred vision in her R eye, wt. loss, and pain in her jaw when chewing. SHe has a history of right shoulder stiffness. On examination, she has right temporal tenderness to palpation and reduced right eye visual acuity. DDx? W/U?

DDx: Temporal arteritis Vasculitis Migraines Cerebral abscesss Cluster HA Tension HA Meningitis Carotid artery dissection Pseudotumor cerebri Trigeminal neuralgia Intracranial neoplasm TMJ disorder W/U: Temporal artery biopsy ESR CRP CBC Doppler U/S - Carotid MRI - brain

50yo F presents with recurrent episodes of BL squeezing H that occur 3-4x a week, typically towards end of work day. Experiencing significant stress in her life and recently decreased her intake of caffeine. Neuro exam is NL. DDx? W/U?

DDx: Tension HA Migraine Caffeine or analgesic withrawal Depression Intracranial neoplasm Cluster HA Pseudotumor cerebri W/U: CBC Electrolytes ESR MRI - brain LP - CSF analysis CT - head

57yo M w/ daily pain in right cheek for past month. Pain is electric and stabbing in character and occurs while he is shaving. Each episode lasts 1 -2 minutes. DDx? W/U?

DDx: Trigeminal neuralgia Tension HA Migraine Cluster HA TMJ disorder Temporal arteritis Intracranial neoplasm W/U: MRI - brain CBC ESR

Depressed mood Key physical exam?

H&N exam Neuro exam MSE (document appearance, behavior, speech, mood, affect, thought process, thought content, cognition (30 point MMSE), insight, and judgment

Key physical exam for loss of vision?

HEENT Fundoscopic Neurologic and Cardio exams