#NeurologyMorningReport Case 8 #MedTwitter Updates & Answers posted later today. Asking your help #MedEd #neurology #neurologyresident Join me in educating. Share your questions and knowledge.
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69 yo woman admitted for work-up of worsening cognition and gait over past 8 months-
8 m ago: some mild forgetfulness 8 m ago
5 m ago: episode of confusion and hallucinations (+UTI and B12 300) improved but not completely
Started donepezil
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8 m ago: some mild forgetfulness 8 m ago
5 m ago: episode of confusion and hallucinations (+UTI and B12 300) improved but not completely
Started donepezil
2/
1m ago confusion worsened, lang probs, gait unsteadiness, BUE tremor. Family noted she seemed to be acting out her dreams.
PMH: HTN, HL, h/o breast cancer, h/o lymphoma
FH: Brother had memory problems.
What would you be looking for on examination?
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PMH: HTN, HL, h/o breast cancer, h/o lymphoma
FH: Brother had memory problems.
What would you be looking for on examination?
3/
Exam:
Alert and pleasant
Unable to:
count backwards from 20 to 1
spell WORLD
Draw numbers on clock face
Give place or date
Name president
Tell events of 9/11
Copy intersecting pentagons
4/
Alert and pleasant
Unable to:
count backwards from 20 to 1
spell WORLD
Draw numbers on clock face
Give place or date
Name president
Tell events of 9/11
Copy intersecting pentagons
4/
Language: tangential otherwise normal
Registers 3/3 and recall 2/3 from a list at 5 min
Motor: high frequency bilateral postural tremor in the hands. There is a bilateral grasp reflex. No cogwheeeling or spasticity
Coordination-FNF shows no dysmetria, mild intention tremor
5/
Registers 3/3 and recall 2/3 from a list at 5 min
Motor: high frequency bilateral postural tremor in the hands. There is a bilateral grasp reflex. No cogwheeeling or spasticity
Coordination-FNF shows no dysmetria, mild intention tremor
5/
Reflexes-2+ UE, 1+ BLE, toes downgoing
Gait- needs assistance of two to stand and ambulate, not stooped or shuffling. Gait is magnetic, unsteady, turns en bloc, cannot tandem
What is highest on your DDX?
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Gait- needs assistance of two to stand and ambulate, not stooped or shuffling. Gait is magnetic, unsteady, turns en bloc, cannot tandem
What is highest on your DDX?
6/
Chemistry, CBC, LFTs normal, ESR 33, CRP 18, ANA negative, RPR non reactive, HIV negative
EEG 2 awake and 1 drowsy examples
LP – opening pressure normal, RBC 0, WBC 1, glucose 70, protein 60
PET-CT brain and body - normal
What else do you want to send from CSF or serum?
7/
EEG 2 awake and 1 drowsy examples
LP – opening pressure normal, RBC 0, WBC 1, glucose 70, protein 60
PET-CT brain and body - normal
What else do you want to send from CSF or serum?
7/
New MRI with contrast normal other than DWI/ADC shown. #neuroradiology #radiology
CSF and Serum paraneoplastic neg
RT-QuIC - positive
T-tau high
1433 inconclusive
9/
RT-QuIC - positive
T-tau high
1433 inconclusive
9/
Dx: #Prion disease (sporadic-#CJD)
She died 1 year after onset of symptoms
Rapidly progressive #dementia
10/
She died 1 year after onset of symptoms
Rapidly progressive #dementia
10/
^Typo in image- lifetime risk of dying from CJD is 1/30,000
RPD = 1. progress from 1st sx to dementia in less than 1-2 years; or 2. known dementia syndrome that declines at an accelerated rate
Dx approach: 1)Hx and PE 2)Lab tests, 3) MRI & LP, then 4) more specific tests
RPD = 1. progress from 1st sx to dementia in less than 1-2 years; or 2. known dementia syndrome that declines at an accelerated rate
Dx approach: 1)Hx and PE 2)Lab tests, 3) MRI & LP, then 4) more specific tests
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