Neuro Cases
A 6-year-old female without a significant past medical history presents for evaluation of frequent unusual episodes for the past 3 months. The episodes consist of sudden activity arrest with staring and minimal eyelid flutter for 10 to 20 seconds occurring 5 to 10 times per day. The patient is unresponsive to voice or tactile stimulation during the episodes. She is able to immediately resume activities without any recollection of the event once the episode finishes. Her teachers have noted that she stares off in class repeatedly and does not seem to be remembering instructions and classroom material. The diagnosis of attention-deficit/hyperactivity disorder had been suggested. One such unusual episode is induced in front of medical staff with hyperventilation.
Absence seizures
79 year old woman, lives with Husband. Husband reports change in memory over a few months. Patient asks repetitive questions. Often forgets how to get home from unfamiliar places. When pushed, husband realises he hasn't let her go outside alone for more than a year and changes happening over many years. Starting to need help getting dressed. Doesn't follow the news on the radio any more.
Alzheimer's disease
A 54-year-old black woman is referred to the neurology clinic by her general practitioner for evaluation of memory problems. The woman is brought to the clinic by family members who are concerned that she has been more forgetful in the past year. They report she has difficulty recalling birthdays and anniversaries and is not managing common household tasks such as cooking and paying bills. Her sister had onset of dementia in her early 40s and was institutionalised because she was unable to care for herself. The woman was last seen by her primary care physician 3 months ago, when she had a routine work-up, which was reported to be unremarkable. Neurological examination revealed no significant abnormalities. Neuropsychological testing demonstrated severe impairment in executive function, deficits in visuo-spatial testing, and delayed speed of processing information. Mini-Mental State Examination score is 20/30.
Alzheimer's disease
A 76-year-old white woman is brought to her general practitioner by her children because she is becoming more forgetful. She used to pay her bills independently and enjoyed cooking but has recently received overdue notices from utility companies and found it difficult to prepare a balanced meal. She has lost 3.5 kg in the past 3 months, and left the water running in her bathtub and flooded the bathroom. When her children express their concerns, she becomes irritable and resists their help. Her house has become more cluttered and unkempt. On a past visit to her physician, she had normal laboratory tests for metabolic, haematological, and thyroid function. The current evaluation reveals no depressive symptoms and 2/15 on the Geriatric Depression Scale short-form. Her Mini-Mental State Examination score is 20/30.
Alzheimer's disease
A 60-year-old man presents with right foot drop, which has developed gradually over the last year and progressed to involve more proximal areas in the last 2 months. The patient reports associated muscle twitching and painful muscle cramps involving the same areas. The neurological examination reveals bilateral lower-extremity weakness, more severe on the right, with associated spasticity, atrophy of the right foot intrinsic muscles, diffuse fasciculations, and hyper-reflexia, with deep tendon reflexes being brisker on the right lower extremity, and a positive right Babinski's sign. Sensation is preserved throughout.
Amyotrophic lateral sclerosis
A 65-year-old woman presents with progressive slurred speech with nasal quality, and episodes of choking on liquids, for the last 4-5 months. Neurological examination reveals facial and tongue weakness; tongue muscle wasting and fasciculations; dysarthria; hypophonic speech; and brisk reflexes throughout (including jaw jerk).
Amyotrophic lateral sclerosis
A 72-year-old woman with rheumatoid arthritis who is known to have misused alcohol for the last 20 years presents after a 10-minute generalised seizure with impaired consciousness and a partial right cranial nerve palsy with obvious deviation of the eye outward and downward. She had recently received infliximab for a flare of her rheumatoid arthritis.
Bacterial meningitis in adults
An 18-year-old male student presents with severe headache and fever that he has had for 3 days. Examination reveals fever, photophobia, and neck stiffness.
Bacterial meningitis in adults
A 40-year-old woman awakens with left-sided facial fullness and a subjective feeling of facial and tongue 'numbness' without objective hypoaesthesia. She also notes left-sided dysgeusia. Later that day she develops left-sided otalgia, hyperacusis, post-auricular pain, and facial discomfort. Left-sided facial palsy ensues, with associated oral incompetence, facial weakness, and asymmetry progressing to complete flaccid paralysis by the next morning. On physical examination, the resting appearance of the left face demonstrates brow ptosis, a widened palpebral fissure, effacement of the left nasolabial fold, and inferior malposition of the left oral commissure. There is complete absence of brow movement, incomplete eye closure with full effort, and loss of smile, snarl, and lip pucker on the affected side. The remainder of the history and physical examination are unremarkable.
Bell's palsy
A 62-year-old woman presents for a routine annual evaluation to her primary care physician. She is being treated for hypertension and diabetes. She smokes 20 cigarettes per day. She has undergone coronary artery bypass grafting subsequent to unstable angina 2 years ago. She does not recollect an episode of sensory or motor deficit or of monocular blindness. She has a regular heart rhythm with a loud systolic bruit audible over her right neck. She has no demonstrable motor or sensory deficits on physical examination. Duplex ultrasonography is consistent with a 50% stenosis of the right internal carotid artery.
Carotid artery stenosis
A 72-year-old man presents with sudden onset of left arm weakness and numbness. He is being treated for hypertension and diabetes, and smokes 20 cigarettes per day. He has undergone coronary artery stenting subsequent to a myocardial infarction 2 years ago. He has a regular heart rhythm. Duplex ultrasonography is consistent with a >80% stenosis of the right internal carotid artery. Contrast-enhanced computed tomography demonstrates a right frontoparietal infarction without evidence of intracranial haemorrhage.
Carotid artery stenosis
A 50-year-old woman presents with numbness and tingling in her hands. The symptoms are worse in her right (dominant) hand and with activities such as holding a book or a steering wheel, or brushing her hair. The discomfort in her hands frequently wakes her at night, and she has to shake or hang her hand out of her bed for relief.
Carpal tunnel syndrome
A 50-year-old woman presents to the emergency department with a history of right-eye swelling and double vision. On examination, she is afebrile but tachycardic. Her right eye is proptotic, swollen, and red. Her left eye is normal. Complete physical examination shows oedema of both ankles. She is a smoker and also reports that she has been diagnosed with a "kidney disorder". Past medical history is positive for antithrombin III deficiency secondary to proteinuria. Past surgical history is negative.
Cavernous sinus thrombosis
A 67-year-old man presents to the emergency department with fever, headache, and right-eye pain. He reports that his condition started 3 weeks ago when he had an upper respiratory tract infection. His headache has become worse in the past 48 hours, and he has started to have severe right-eye pain, with associated nausea and vomiting. Self-treatment with warm compressors provides little relief. Past medical history is positive for hypertension, type 2 diabetes, and osteoarthritis of the knees. On physical examination, he appears acutely ill, with a temperature of 39°C (102°F). His head and neck examination is notable for bilateral peri-orbital swelling, tense bilateral proptosis, and both internal (blunted papillary response to light) and external ophthalmoplegia. Nasal examination shows purulence above the inferior turbinates.
Cavernous sinus thrombosis
A 2-year-old boy, born after a normal pregnancy and delivery, presents with an asymmetric gait. Examination reveals mild spasticity of the left upper and lower extremity, hyperactive left knee and ankle deep tendon reflexes, and decreased dorsiflexion of the left ankle compared with the right. When walking, the patient walks on his left toes, and his left arm is held mildly flexed at the elbow with the palm facing the floor (pronated forearm). The left calf is smaller in girth than the right, leading to the diagnosis of hemiplegic CP.
Cerebral palsy
An 18-month-old child with a history of prematurity (28 weeks' gestation, 1200 grams) presents with failure to meet developmental milestones. The child sat independently at 1 year, has few words vocally, does not pull to stand, and exhibits increased deep tendon reflexes in the lower extremities, and sustained clonus at both ankles. There is good upper-extremity function. A magnetic resonance imaging scan of the brain reveals periventricular leukomalacia. The child is diagnosed with spastic diplegic CP.
Cerebral palsy
A 22-year-old man was involved in a motor vehicle accident 12 months earlier. He was driving under the influence of drugs and alcohol when the car crashed into a tree, and he was not wearing a seatbelt. He was taken to the accident and emergency department where he was found to have sustained a tear-drop fracture of C6. A neurological assessment determined that he had tetraplegia without sacral sparing. He underwent an emergency C6 vertebrectomy, cord decompression, and anterior stabilisation but the neurological deficit did not improve. He was transferred to a spinal cord rehabilitation facility 2 weeks later. Over the previous 12 months, he has undergone extensive rehabilitation, including bladder care and prevention of joint contractures due to increasing spasticity. He is dependent on his wheelchair.
Chronic spinal cord injury
A 44-year-old man presents with a 3-month history of thoracic pain that has increased in severity in the previous 3 weeks. The pain eases by lying flat, but keeps him awake at night. He has noticed a weight loss of 20 kg in the previous 3 months associated with a loss of appetite and frequent night sweats. He has been through a rehabilitation programme for alcohol abuse. In the previous 3 weeks he has noticed that he has a progressively unsteady gait and has had frequent falls. He has noticed sharp burning paraesthesias in both lower extremities and the lower abdomen, which coincide with the onset of the severe back pain. On examination of his lower limbs, he has spasticity, brisk deep tendon reflexes, extensor plantars, and a sensory level of T6 affecting proprioception, light touch, and pinprick. He has a sharp tenderness over T6, with an angular kyphosis of T5 and T6. In due course, he was transferred to a spinal
Chronic spinal cord injury
A 44-year-old male smoker presents with a 9-year history of recurrent headaches. Headaches occurred twice-monthly initially, always in the early hours of the morning (2 a.m. to 3 a.m.). The headaches have increased to an average of two episodes per day. The acute episodes can occur at any time, and last between 2 and 4 hours. He always has a nocturnal event. Attacks are triggered immediately after drinking alcohol or with the smell of strong aftershave or petrol. The pain is excruciating and focused around his right eye. The right eye reddens and tears, the right eyelid droops, and the right nostril runs. He becomes severely agitated during attacks, often pacing the room or rocking back and forth. Physical examinations, lumbar puncture, brain magnetic resonance imaging (including pituitary views), and pituitary function blood tests are normal.
Cluster headache
A 78-year-old woman presents with confusion, agitation, and visual hallucinations. She has become progressively confused over the past 2 years and has had trouble managing her affairs, including shopping and paying bills. It is unclear when her confusion started. Initially, she was having trouble following conversations and got lost on several occasions. Her memory, which was previously good, has begun to deteriorate. At night, she sees children playing in her house and has called the police on several occasions. She gets angry easily and has been paranoid about her relatives and their intentions. Her behaviour tends to fluctuate from day to day. She started to shuffle about 6 months ago and had difficulty getting out of chairs, and getting dressed to go out seemed to take hours. On one occasion, she fell and was taken to the emergency department but was subsequently discharged with no diagnosis given.
Dementia with Lewy bodies
A 54-year-old woman with type 1 diabetes has developed an ulcer on her right foot. She cannot recall any particular injury and has been walking as normal with no pain. Physical examination of the foot reveals a painless ulcer over the metatarsal head. She also complains of feeling tired and has noticed she is particularly dizzy and unsteady on her feet when she stands up. Blood pressure (BP) measurements in the supine position, repeated after 2 minutes of standing, reveal an abnormal fall in systolic BP, from supine to standing position, of 32 mmHg.
Diabetic neuropathy
A middle-aged man with type 2 diabetes presents with shooting and burning pain in his feet and lower legs, most severe at night, associated with numbness and allodynia (pain from stimuli that are not normally painful). In the past 6 months, the pain has become much worse and disturbs his sleep. He has been told that his blood glucose is borderline elevated and has been advised to start diet and exercise. He also takes a medication for hypertension and recalls that his cholesterol is elevated.
Diabetic neuropathy
A 19-year-old man presents to the emergency department with a witnessed generalised tonic-clonic seizure episode. One month previously he had an upper respiratory tract infection. Over the last 2 weeks he developed headaches, blurred vision, generalised weakness, and progressive difficulty in walking. Examination revealed pain on eye movement as well as limb and gait ataxia.
Encephalitis
A 56-year-old man presents to the emergency department with headache, fever, blurred vision, and somnolence followed shortly by unresponsiveness to verbal commands. For the last 2 weeks he had been feeling ill and had decreased appetite and myalgias. Three days prior to presentation he experienced intermittent confusion, severe headache, and fever. Examination was limited by a generalised tonic-clonic seizure, for which he received lorazepam.
Encephalitis
A 68-year-old woman presents with a complaint of 'shaking hands'. She reports a 10-year history of bilateral hand tremor that has slowly progressed and is worse in her right hand. It mainly bothers her when she is using her hands for various tasks. She has great difficulty drinking from cups and eating peas and other foods, and uses either a straw or both hands to eat and drink. She also finds writing and sending text messages problematic. She has come to rely increasingly on her spouse for assistance with activities of daily living, and has retired from work as a secretary. She has stopped eating out in restaurants because of the social embarrassment. She denies any slowness of movement, rigidity, or cramping. Her father has a long history of tremor, but otherwise she has no personal or family history of neurological diseases. When the patient has a glass of red wine, she notes that her tremor abates.
Essential tremor
A 42-year-old woman presents to her primary care physician with a 7-week history of an enlarging mass on the left side of her neck. She denies pain or drainage. The mass failed to respond to antibiotics. She denies cough, fever, night sweats, or anorexia. She is originally from Vietnam but has lived in the US for 4 years. She denies any history of TB or TB exposure. Physical examination reveals a well-appearing woman. There is a 2 x 4 cm left neck mass consistent with a lymph node in the anterior cervical chain. There is no tenderness; the node is firm and mobile. There are smaller subcentimetre lymph nodes in the left supraclavicular fossa. The physical examination is otherwise unremarkable.
Extrapulmonary tuberculosis
A 10-month-old girl is brought to the emergency department with a history of recurrent right arm and leg jerking followed by prolonged sleepiness. The parents report a 2-day history of fever with chest congestion and irritability. The child is admitted to hospital for neurological evaluation.
Febrile seizure
A previously healthy and developmentally normal 18-month-old boy presents to the emergency department by ambulance after his parents witnessed a seizure. The parents report the boy had a febrile illness with mild upper respiratory symptoms and they treated him with paracetamol at home. The child then began to have frequent jerking movements of all limbs. The temperature was 39.5°C (103.1°F). The parents called the emergency services, and the child was taken to the emergency department. The jerking stopped after approximately 5 minutes. Afterwards, the child was sleepy but responsive to verbal stimulation. Examination revealed a diffuse erythematous maculopapular rash and a normal mental and neurological status.
Febrile seizure
A 70-year-old man presents with a tonic-clonic seizure. His wife states that during the past month there have been times when he does not respond when spoken to, mumbles words that do not make sense, and stares in a motionless way. After several minutes he is usually responsive. His past medical history includes hypertension and hypercholesterolaemia. He had a stroke during the preceding year, which resulted in weakness of the right extremities and loss of expressive language. Although he recovered most motor and language deficits, he still walks with a limp on the right side and sometimes uses the wrong word.
Focal seizures
An 18-year-old girl presents with several episodes of confusion over the past several months. Typically, she experiences a warning signal, which she describes as a rising sensation within her abdomen that travels upwards through her chest. She is usually unaware for a few minutes, but others have told her that during these episodes she smacks her lips, picks at her clothing, and is unable to speak. After the event she feels tired, has a headache, and prefers to lie down. She notes that her memory has not been as good as it was in the past, and her school grades have declined. Her medical history is notable for several febrile seizures as a young child, although she was not treated for seizures at that time. An aunt was diagnosed with seizures many years ago.
Focal seizures
65 year old man, recently retired, lives with wife Referred to clinic by GP as concern with 'un usual behaviour'. Seen with wife who is very distressed. Recently retired and become disinterested in things at home. Doesn't concentrate on TV but will sit in front of it all day long. Used to do all the washing/ironing but now keeps stopping part way through leaving the iron on. Wife gets very tearful and frustrated but patient laughs in response. Has been making inappropriate sexual comments to their female neighbours.
Frontotemporal dementia
A 55-year-old man who worked as a technician developed difficulty finding words 2 years earlier, which has evolved into dysfluency, frequent repetition of remarks and questions, stereotypies (purposeless behaviours or fragments of speech frequently repeated, without regard to context), and echolalia (reflexive repetition of another's speech). In the past year, he has also become forgetful. His work efficiency deteriorated due to his poor comprehension, reasoning, planning, and completion, resulting in disability leave. He also became unfeeling, intrusive (indiscriminately approaching strangers), child-like, and impulsive. He developed rigid routines (e.g., insistence on the same TV shows) and coarse manners (e.g., eating out of serving bowls, jumping queues, and walking away from conversation). Restlessness is marked: each day he bikes, swims many laps, runs 10 km, and 'volunteers' at a local nursing home, making the
Frontotemporal dementia
A 16-year-old boy presents to the emergency department with a first-time seizure event after attending an all-night party and consuming alcohol. Witnesses described the seizure as beginning abruptly with bilateral limb stiffening, followed by jerking movements in all limbs; the patient has no memory of warning symptoms prior to the seizure. The event seemed to last about 1 minute, and the patient was quite somnolent afterwards. Further review of the history reveals that the patient has been experiencing 'jerks' in the morning after awakening, usually involving the arms and shoulders and occasionally causing him to drop things. These 'jerks' do not seem to present a problem during the rest of the day.
Generalised seizures
A 55-year-old woman recently diagnosed with a brain tumour in the left hemisphere has a witnessed seizure event. The seizure is initially recognised when the patient begins staring and is unresponsive to those around her. She seems to be picking at her clothes with her left hand, but the right arm and leg are not moving. After 20 seconds, she displays rapid head-turning and eye deviation to the right, with tonic extension of the right arm and flexion of the left arm. This is quickly followed by tonic extension of the left arm, then clonic jerking occurring in both arms synchronously. This jerking gradually slows and stops after about 30 seconds. The patient then becomes quite somnolent, and she appears to be using her arm and leg less on the right than the left.
Generalised seizures
A 10-year-old girl presents after having had a generalised tonic-clonic seizure while at school the previous day. It lasted approximately 2 minutes and she was incontinent of urine during the episode. Afterwards she complained of headache and feeling tired. She had been well prior to this episode and there is no family history of epilepsy. General physical examination including neurological assessment on the day after the seizure were both normal. An ECG was done, which was normal and showed a normal QTc interval.
Generalised seizures in children
A 15-year-old boy presents with a history of having had two seizures. He is healthy and has no relevant past medical history. There is no family history of epilepsy. Both episodes happened early in the morning and were self-limiting. Jerking of the whole body and all four limbs lasted <5 minutes, and he was sleepy for several hours after the episodes. His general examinations, including blood pressure, a random blood sugar, and an ECG, were normal.
Generalised seizures in children
A 72-year-old woman of Northern European ancestry presents with partial vision loss in the right eye. She reports bitemporal headache for several weeks, accompanied by pain and stiffness in the neck and shoulders. Review of systems is positive for low-grade fever, fatigue, and weight loss. On physical examination, there is tenderness of the scalp over the temporal areas and thickening of the temporal arteries. Fundoscopic examination reveals pallor of the right optic disc. Bilateral shoulder range of motion is limited and painful. There is no synovitis or tenderness of the peripheral joints. There are no carotid or subclavian bruits, and the blood pressure is normal and equal in both arms. The remainder of the examination is unremarkable.
Giant cell arteritis
A 35-year-old right-handed man presents with a focal motor seizure involving his right arm and the right side of his face. He also reports left-sided headaches for a few months and clumsiness of his right hand. On examination he is awake and orientated. He has a subtle facial droop and pronator drift on the right side.
Gliomas
A 20-year-old woman with no significant past medical history presents with lower back pain and bilateral foot and hand tingling. Her symptoms rapidly progress over 4 days. She develops lower extremity weakness, to the point that she is unable to mobilise her legs. She reports coryzal symptoms 2 weeks ago. On examination, she has 0/5 power in her lower extremity with areflexia, but despite the paraesthesias she does not have sensory deficits. Her aminotransferases are elevated, and lumbar puncture reveals mildly elevated protein with no cells and normal glucose. She weighs 70 kg and her admission vital capacity is 1300 mL, maximum inspiratory pressure is -30 cmH₂O, and maximum expiratory pressure is 35 cmH₂O.
Guillain-Barre syndrome
A 50-year-old man presents to the emergency department with a history of black, tarry stools but denies haematemesis or abdominal pain. His family has noticed progressive confusion. He has alcohol-related liver disease with cirrhosis. His heart rate is 112 bpm and blood pressure is 105/66 mmHg. He is jaundiced and lethargic, is oriented to person and place but not date, and has moderate ascites. Neurological examination reveals asterixis, and stool is positive for occult blood.
Hepatic encephalopathy
A 65-year-old woman presents with generalised headache and burning pain in her left temporal area. Eight days after onset of the pain, several facial lesions are noted. On physical examination, she is afebrile. An erythematous tender plaque is present on the left frontal scalp area. Three smaller similar plaques are present on the left temple and cheek.
Herpes zoster infection
A 77-year-old man reports a 5-day history of burning and aching pain on the right side of his chest. This is followed by the development of erythema and a maculopapular rash in this painful area, accompanied by headache and malaise. The rash progresses to develop clusters of clear vesicles for 3 to 5 days, evolving through stages of pustulation, ulceration, and crusting.
Herpes zoster infection
A 42-year-old school teacher presents with difficulty managing her classroom. She has become increasingly irritable with students and fails to complete assigned tasks on time. Her sister and husband report that she has become restless, pays less attention to her appearance and social obligations, and at times is anxious and upset. She has stumbled unexpectedly. Her symptoms resemble those of her mother when she was diagnosed with Huntington's disease. On examination, her speech is somewhat uneven and she is inappropriately flippant. Subtracting serial 7s from 100, while seated with her eyes closed, brings out random 'piano-playing' movements of the digits along with other movements of the limbs, torso, and face. Subtraction errors occur with this task. She is unable to keep her tongue fully protruded for 10 seconds. Finger tapping is slower than the examiner's, and tapping tempo is uneven. Tandem walking is impaired.
Huntington's disease
A 29-year-old woman presents with a 3-month history of worsening headaches and increasing visual loss. She describes occasional episodes of bilateral visual greyouts lasting 20 seconds that may be precipitated by bending forwards or standing. Over the last 2 weeks she has often heard a 'whooshing' sound in both ears, synchronous with her pulse, that is more noticeable when she is about to go to sleep. Her visual acuity is 20/30 (6/9 metres) in each eye. Fundus examination shows bilateral optic disc swelling, and Humphrey automated perimetry shows enlargement of the blind spot and scattered abnormal test locations. Magnetic resonance imaging shows a partially empty sella, and a magnetic resonance venogram shows no evidence of a thrombosis but does demonstrate bilateral transverse sinus venous stenoses. Lumbar puncture opening pressure is 280 mm H2O.
Idiopathic intracranial hypertension
A 70-year-old right-handed man is discovered by a family member to have difficulty speaking and comprehending spoken language, and an inability to raise his right arm. He was last known to be fully functional 1 hour ago when the family member spoke to him by phone. There is a history of treated hypertension and diabetes.
Ischaemic stroke
70 year old man, lives alone Admitted via A and E with a fall. Recent car accident after driving wrong way down street. Concern from GP as has been showing up to practise for appointments on wrong day, or from previous day. GP noticed a shuffling gait and some stiffness on examination. Concern from A and E nurses as reporting seeing small animals and children in ward. Speaking to Nephew, he has been saying things like this for the last year.
Lewy body dementia
An 18-year-old man presents in July with a 1-week history of non-pruritic, erythematous rash with low-grade fever and arthralgias. On examination, the patient has multiple skin lesions, about 4 cm to 10 cm in diameter, with central clearing. The patient had significant outdoor exposure, but there was no recollection of a tick or insect bite.
Lyme disease
A 6-year-old boy presents with 3 to 4 weeks of morning headaches and intermittent vomiting without fever. The headaches improve throughout the day. Over the past 2 days, the headaches are lasting longer and the vomiting is more frequent, but after vomiting the headaches are much improved. The headaches are not localised to one side. On the day of presentation, the parents note that he is walking like a 'drunken sailor'.
Medulloblastoma
A 60-year-old man presents with progressive headache and cognitive decline. A MRI of the brain without gadolinium enhancement demonstrates a large extra-axial lesion that is similar intensity to brain on T1 images.
Meningioma
A 32-year-old woman presents with a 13-year history of 1-3 attacks per month of disabling pounding pain over one temple, with nausea and sensitivity to light. She says that her headaches can be triggered by lack of sleep and made worse by physical exertion, and are more common during menstrual bleeding. Untreated, they last for 2 days. On four occasions, headaches were preceded by the gradual appearance of a shimmering, zigzag line that enlarged, moved to the peripheral visual field, and then faded away over 45 minutes. Examination is normal.
Migraine headache in adults
A 40-year-old man complains of a 1-year history of twice-monthly global headache, worse on the left side in the post-auricular region. It comes on gradually and, at its most severe, the vision in his left eye becomes distorted. He often has to stop watching television as the picture becomes 'blurry'. His nose becomes blocked, although sometimes he has a 'runny nose'. He takes a non-steroidal anti-inflammatory drug (NSAID) that helps a little, but he feels that his head is about to explode at times. When the headache occurs, he needs to go into a dark quiet room and sleep until it resolves. He reports that the problem is "really getting him down", and he is having difficulties with his employer due to loss of work time.
Migraine headache in adults
A 9-year-old boy presents with a 6-month history of recurrent headaches. He does not experience aura. Each headache builds up gradually over 20 minutes and is usually unilateral in nature, pulsating in quality, of moderate intensity, and aggravated by exercise. Nausea, vomiting, photophobia, and phonophobia are common accompanying symptoms. During attacks he favours going to sleep in a dark room, and will often go to bed earlier than usual and wake fully recovered the next day. Attacks can be of variable duration (2 to 48 hours) but generally last around 16 hours. Neurological examination during an attack is entirely normal. He is normotensive. He is completely well in between attacks and is making good academic progress. There is a strong family history of migraine with aura.
Migraine headache in children
A 28-year-old white woman who has smoked 1 pack per day for the last 10 years presents with subacute onset of cloudy vision in one eye, with pain on movement of that eye. She also notes difficulty with colour discrimination, particularly of reds. She was treated for a sinus infection 2 weeks ago and, on further history, recalls that she had a 3-week history of unilateral hemibody paraesthesias during examination week in university 6 years ago. She occasionally has some tingling on that side if she is overly tired, stressed, or hot.
Multiple sclerosis
A 31-year-old woman with strong family history of autoimmune disease is 6 months postnatal and develops ascending numbness and weakness in both feet, slightly asymmetrically, over a period of 2 weeks. She gradually develops difficulty walking to the point where she presents to an emergency department and is also found to have a urinary tract infection.
Multiple sclerosis
A 25-year-old woman presents with recurrent slurring of speech that worsens when she continues to talk. She has trouble swallowing, which deteriorates when she continues to eat, and has double vision that gets worse when sewing, reading, or watching TV. She reports that her head is heavy and hard to hold up. Her symptoms have progressively deteriorated over the past 6 months. She has intermittent weakness in her legs and arms. She is fearful of falling due to her legs giving way and she has trouble combing her hair or putting on deodorant. She reports a feeling of generalised fatigue and is occasionally short of breath.
Myasthenia gravis
A 76-year-old man reports double vision for the past 2 months. Within the past 2 weeks he has developed bilateral ptosis (drooping eyelids). His ptosis is so severe at times that he holds his eyes open to read. He is unable to drive due to the ptosis and diplopia (double vision). His symptoms are generally better in the morning and get worse throughout the day.
Myasthenia gravis
A 60-year-old man presents with syncope while walking outside with his wife. His wife recalls the patient looking at the sky to point out an aeroplane. He then appeared pale and collapsed to the ground, suffering a head laceration in the process. The history suggested the possibility of carotid sinus syndrome (CSS). In the laboratory, carotid sinus massage was undertaken while the patient was in the upright posture on a tilt table. The massage induced 10 seconds of asystole with near loss of consciousness. A dual-chamber pacemaker was implanted on the basis of a presumptive diagnosis of CSS; there was no recurrence of syncope during the next year. This patient has had no further faints but occasionally becomes dizzy when turning his head abruptly.
Neurally mediated reflex syncope
An 18-year-old man presents to a clinic reporting two episodes of loss of consciousness. The first episode occurred 1 year earlier while playing dodgeball in gym class. He recalls diving to the ground to avoid being hit. On getting up quickly, he noticed feeling lightheaded, sweaty, and nauseated. Apparently, he fell to the ground but does not recall having done so. He later recalls waking up in an accident and emergency (A&E) department. Witnesses reported shaking and clenching of both hands after he had fallen. In the A&E department he was given phenytoin intravenously because of concern that he may have had a seizure. After a negative work-up in hospital he was prescribed carbamazepine, despite no abnormalities on an electroencephalogram. A year later he had a second episode of loss of consciousness while doing bicep curls. He denies palpitations, tongue biting, or incontinence. He experienced a similar prodrome o
Neurally mediated reflex syncope
A 69-year-old man presents with a 1-year history of mild slowness and loss of dexterity. His handwriting has become smaller, and his wife feels his face is less expressive and his voice softer. Over the last few months he has developed a subtle tremor in the right hand, noted while watching television. His symptoms developed insidiously but have mildly progressed. He has no other medical history, but he has noted some mild depression and constipation over the last 2 years. His examination demonstrates hypophonia, masked facies, decreased blink rate, micrographia, and mild right-sided bradykinesia and rigidity. An intermittent right upper extremity resting tremor is noted while he is walking. The rest of his examination and a brain magnetic resonance imaging are normal.
Parkinson's disease
A 50-year-old man presents with a relatively rapid 2-year decline in cognitive function. Symptoms began with behavioural changes and progressed to short-term memory loss, tremor in his left arm, and ataxia, and development of a shuffling gait. One year later, he developed depression, worsening bradykinesia, slurred hypophonic speech, and trouble swallowing. Family history includes a mother who died of an undiagnosed type of dementia with onset in her late 50s.
Prion disease
A 68-year-old woman presents with word-finding difficulty, which comes on slowly and progresses over several weeks. Her family has noted some confusion, cognitive decline, blunted affect, and difficulty with gait. General blood tests are normal and evaluations are negative for HIV, Lyme disease, and bacterial, fungal, and viral infections.
Prion disease
A 40-year-old woman presents with skin lesions around her nose, which are indurated plaques with discoloration. She also reports a red, moderately painful right eye with blurred vision and photophobia.
Sarcoidosis
A 50-year-old woman presents with shortness of breath, cough, and painful red skin lesions on the anterior surface of the lower part of both legs. Chest x-ray reveals bilateral hilar lymphadenopathy with pulmonary infiltrates.
Sarcoidosis
A 25-year-old man presents to the emergency department after an automobile accident. He was ejected from the vehicle. He complains of numbness in both lower extremities and cannot move his legs. There is no pinprick sensation below the umbilicus except for an anal wink, and there is no rectal tone. The bulbocavernosus reflex is weakly present. Power in the lower extremities is graded at 1/5.
Spinal cord compression
A 40-year-old woman presents with back pain and difficulty with her gait. She has a long history of smoking and has had some haemoptysis recently. Her examination reveals diminished pinprick sensation from the nipple line caudally, power in the lower extremities of 4/5, absent joint position sense in the lower extremities, and diminished vibratory sense. Anal sphincter tone is intact.
Spinal cord compression
A 45-year-old homeless man is found unconscious in the street. He appears stiff, with continuously shaking extremities, foaming at the mouth, and urinary incontinence. On arrival at the accident and emergency department, he has stopped shaking but is still unconscious. Stiffening and shaking resume a few minutes later. Two empty medicine bottles are found in his pocket, labelled phenytoin and valproic acid.
Status epilepticus
A 70-year-old man with a history of chronic hypertension and atrial fibrillation is witnessed by a family member to have nausea, vomiting, and right-sided weakness as well as difficulty speaking and comprehending language. The symptoms started with only mild slurred speech before progressing over several minutes to severe aphasia and right arm paralysis. The patient is taking warfarin.
Stroke due to spontaneous intracerebral haemorrhage
A 53-year-old black woman presents with a sudden, excruciating headache which started while sitting at work. The headache is diffuse, intense, and accompanied by nausea and vomiting. She describes the headache as the worst headache of her life. She loses consciousness following onset of the headache and is on the floor for less than 1 minute. She is being treated for hypertension and is a smoker. On examination she has a normal mental state, meningismus, bilateral subhyaloid haemorrhages, and right third cranial nerve palsy. There are no sensory deficits or weakness. Brain computed tomography (CT) reveals diffuse subarachnoid blood in basal cisterns and sulci.
Subarachnoid haemorrhage
A young man is brought to the emergency department after being involved in a high-speed motor vehicle accident. He was an unrestrained driver, and no airbags were deployed. He has multiple areas of abrasions, lacerations, and ecchymosis on his scalp and face. On neurological examination, he does not open his eyes to painful stimuli; he is intubated, and he withdraws his left side to pain. His right side is plegic. His right pupil is 3 mm and reactive to light and his left pupil is 8 mm and non-reactive.
Subdural haematoma
An older man with a longstanding history of atrial fibrillation on anticoagulation with warfarin is brought into the emergency department by his carer, who states his concern about the patient's confusion at home. The carer describes frequent falls over the last several months and says that the patient is dropping utensils from his right hand. On neurological examination, his pupils are equal, round, and reactive to light. He has a right-sided pronator drift and is weaker on his right side than on his left. His mental status testing reveals poor concentration and attention, and impaired short- and long-term recall and registration.
Subdural haematoma
A 27-year-old man notes a painless penile ulcer. He has recently started a new relationship. He is otherwise asymptomatic, as is his partner. On examination, the ulcer is indurated and the inguinal lymph nodes are rubbery and moderately enlarged.
Syphilis infection
A 30-year-old man presents with difficulty hearing conversations while in a crowded room. Following referral for audiometry, bilateral high-frequency hearing loss is diagnosed. On further questioning he reports a past history of an anal fissure about 10 weeks previously that healed spontaneously. He also describes a mild transient skin rash 2 weeks before his auditory symptoms appeared. He says that he has been feeling unusually tired.
Syphilis infection
A 37-year-old woman presents with a 12-year history of episodic headaches. She experiences these 4 times a week, typically beginning at the end of a working day. The pain is generalised and described as similar to wearing a tight band around her head. The headaches are bothersome, but not disabling, and she denies any nausea or vomiting. She is slightly sensitive to noise but has no photophobia. Pain during her attacks typically responds to ibuprofen. Examination reveals tenderness of her scalp and both trapezius muscles.
Tension-type headache
A 56-year-old man presents with a 25-year history of constant headache. The onset was insidious and he is certain that the only time he is headache-free is when he sleeps. He states the headache is generalised and his neck and shoulders are always 'tight'. He denies any associated autonomic symptoms including eye tearing, nasal congestion, light and sound sensitivity, nausea, or vomiting.
Tension-type headache
A 67-year-old man with a prior history of hypertension, diabetes, hyperlipidaemia, and a 50 pack-year smoking history noted rapid onset of right-sided weakness and subjective feeling of decreased sensation on his right side. His family reported that he seemed to have difficulty forming sentences. Symptoms were maximal within a minute and began to spontaneously abate 5 minutes later. By arrival in the accident and emergency department 30 minutes after onset, his clinical deficits had largely resolved with the exception of a subtle weakness of his right hand. Forty minutes after presentation, all of his symptoms were completely resolved.
Transient ischaemic attack
67 year old man, lives alone Admitted to hospital recently due to self-neglect at home. Had been fine up until two years ago, very active in local bowls club. Now, unable to play. Concern from bowls club members led to safe guarding assessment. Used to be very knowledgeable about golf and other sports but stopped around 18 months ago. Had been doing well up until now. During admission, episode of slurred speech lasted around 3 hours.
Vascular dementia
A 65-year-old man presents with difficulty in decision-making and planning, which is of abrupt onset and occurs 3 months after a stroke. He has strong vascular risk factors, including smoking. Over time, there has been a fluctuating stepwise reduction in cognitive function. There is a history of nocturnal confusion and incontinence. On examination there is evidence of focal neurological deficit with pseudobulbar palsy and extrapyramidal signs. Neuroimaging indicates a probable vascular aetiology with white matter changes and infarction.
Vascular dementia
A 30-year-old woman underwent bariatric surgery for Class III (BMI ≥40) obesity. The postoperative course was complicated by a bronchopneumonia, vomiting, and poor oral intake. Four weeks after surgery she complained of vertigo and headache and soon became apathetic and developed vertical nystagmus that was worse on downward gaze.
Wernicke's encephalopathy
A 40-year-old man with a history of alcohol-misuse is brought to the emergency department by police, who found him lying down by the side of the street. On examination he is somnolent and confused. He has a horizontal gaze palsy with impaired vestibulo-ocular reflexes and severe truncal ataxia in the presence of normal motor strength and muscle stretch reflexes.
Wernicke's encephalopathy
A 55-year-old man presents with a 2-year history of polyarthralgia, intermittent fever, weight loss, and diarrhoea. The seronegative polyarthritis has been treated with immunosuppressive drugs without improvement. Lymphadenopathy was reported for the mesenteric and retriperitoneal lymph nodes. Gastroscopy shows mucosal abnormalities in the duodenum. Histological examination of duodenal biopsies reveals numerous foamy macrophages in the lamina propria that contain large amounts of diastase-resistant periodic acid-Schiff (PAS)-positive particles in the cytoplasm.
Whipple's disease
A 61-year-old man presents with memory impairment, decreasing level of consciousness, and progressive supranuclear ophthalmoplegia in conjunction with oculomasticatory myorhythmia (pendular vergence oscillations of the eyes and synchronous 1 Hz to 3 Hz contractions of the masticatory, but not palatal, muscles). The patient reports occasional headache and occasional articular pain. Laboratory investigation of the spinal fluid shows slightly elevated cell numbers and inflammatory parameters. Microbiological analysis of the spinal fluid is negative. Gastroscopy shows a normal mucosal macroscopy, but a histological examination of duodenal biopsies reveals diastase-resistant PAS-positive macrophages in the lamina propria.
Whipple's disease
