Neurology Clerkships
Case 1  
Author: Eric Kraus, MD
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This is a 25-year-old, right handed female, who has had visual changes for one month. The first symptom was trouble reading; specifically, that half of the words on the right were missing. While reading the newspaper she would need to turn her head to finish a line or a sentence. The right visual field was "dark and blurry." No diplopia. She was referred to an ophthalmologist who found mild myopia and normal visual field testing.

The visual problems slowly progressed and new symptoms surfaced. These include word substitutions (paraphasias), dizziness, and transient leg numbness. The dizzy feeling is "off balance" noted with position change. She denies vertigo, tinnitus, hearing trouble, or gait difficulties. Two episodes of leg numbness each lasted 30 secs. The first involved both legs and the second only part of the left leg.

A repeat eye exam three days ago revealed a right superior visual field deficit on computerized testing.

Review of systems is positive for a dog bite on the forehead approximately six to eight months ago, inability to drive and poor work performance. She denies headache, eye pain, limb weakness, permanent numbness, dysarthria, history of seizures, and bowel or bladder change. Two years ago the patient had mild numbness in her right
face lasting about 2 weeks for which she did not seek medical care.

PMH: Right orbital fracture repair at age 8.

1. Tetracycline.

1. Cephalexin, which causes a rash.

Family History: Father was diagnosed with multiple sclerosis at age 35 and died from this disease.

Social History: Works as a private investigator. Single. Rare alcohol. No smoking or illicit drugs.

BP 112/60   HR 84    T 37.2°C
General: Thin. No acute distress.
Mental Status: Alert and oriented x 3.
HEENT: Her head was normocephalic and atraumatic. Neck was supple, with full range of motion. The pupils were equal, round and reactive to light and there was no relative afferent pupillary defect. Extraocular movements were intact without nystagmus. Visual field testing was full to confrontation. Optic discs were sharp bilaterally with venous pulsations present. There was no facial weakness. Facial sensation was intact in the V1 through V3 distributions bilaterally. The palate elevated symmetrically. The tongue was midline and strong.
Motor (Power/Tone/Bulk): 5/5 bilaterally in the upper and lower extremities. Tone mildly spastic in the left leg. No atrophy.
Sensory: Sensation was intact to light touch, pin prick and proprioception bilaterally in the upper and lower extremities. Romberg was absent.
Reflexes: 2+/4 at the left biceps, triceps, brachioradialis, patella and Achilles, and 2/4 on the right. The asymmetry is present in two positions. There was a trace Hoffman sign on the left. Toes were downgoing to plantar stimulation bilaterally.
Coordination: Finger-to-nose and rapid alternating movements were intact bilaterally.
Gait: Steady, without ataxia. Tandem walking was intact.
Abnormal Movements: None
Other Organs: Noncontributory.

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