Case 10
CASE 10: DESCRIPTION
55 year-old man comes in the ER for confusion and balance problems. Friends found him down after a fall. They called 911 after he was unable to get up and walk straight. The patient says he has felt dizzy like he is walking on a boat, intermittent double vision, worsening over the past couple of weeks. He mainly drinks beers, about 7 per day.
Social: marginally housed, identifies as Caucasian
Exam: 160/80, HR 80, RR 12, O2 sat 98% RA
General Exam: disheveled, smells of alcohol
Neurologic Exam:
Mental status: Alert, oriented x 3. Follows commands. Intact language, naming. Delayed recall 2/3
CN: No VF cuts, restriction of eye movements and reports diplopia on leftward or rightward gaze, +nystagmus
Motor: 5/5 strength throughout, low to normal tone, bulk cachexic
Sensory: normal
Reflexes: 1+ throughout, toes mute
Coordination: Slow, imprecise finger taps; mild dysdiadochokinesia on rapidly alternating movements (RAM), slight intention tremor bilaterally on finger-nose-finger; marked dysmetria on heel-knee-shin testing.
Gait: wide-based staggering gait, marked difficulty with tandem