Case Study 1 A 50-year-old left-hand-dominant man

Case Study 1 A 50-year-old left-hand-dominant man presents to his primary care physician with complaints of right-hand weakness. He says 6 months ago he began dropping things with his right hand. In the subsequent months, his grip strength has weakened further and his handwriting has deteriorated. He has also noticed frequent twitching in the muscles of his right hand, forearm, and shoulder, and he has developed painful muscle cramps in his neck and back. He also reports occasional problems swallowing his food and says his speech seems “thicker.” The patient reports no other significant past medical history and denies any lower extremity disturbances or sensory deficits. Vital signs are within normal limits. The patient’s cranial nerve examination is significant for atrophy of the tongue, which also demonstrates fasciculations upon protrusion. On motor exam, the patient has significant thenar atrophy of the right hand, but not on the left. Right hand strength is 3/5, and left hand strength is 4/5. Triceps and biceps are 4+/5 bilaterally and deltoids are 5/5 bilaterally. Neuromuscular examination of the lower extremities is normal. Reflexes are 3+ in the upper extremities bilaterally and he also has a brisk jaw jerk reflex. Sensory examination is normal. The patient’s gait is normal, and he exhibits no ataxia. Questions What is the most likely diagnosis? What is the etiology of this condition? What are the clinical manifestations of this condition? Case Study 2 An 80-year-old woman is brought to her nurse practitioner by her daughter for a medication check. During the visit, the patient has trouble answering questions about events that took place in the past month, and at one point stops to ask her daughter where she is. Her daughter comments that she has recently been disoriented in familiar environments, that she has trouble coming up with the names of people and objects, and that she recently forgot to turn off the stove at home, setting off the fire alarm. Vital signs are as follow: Temperature = 36.5°C; HR = 90/min; BP = 130/80 mm Hg. Neurologic examination reveals no focal deficits, but she scores a 22/30 on the Mini-Mental State Examination, losing points because she is not oriented to the date or day of the week, is unable to recall words that she has been asked to remember after a brief delay, and is unable to copy a simple figure. Questions What is the most likely diagnosis? What is the etiology of this condition? What are the clinical manifestations of this condition? Case Study 3 An 18-year-old woman is brought to the ED by EMS after a motor vehicle accident (MVA). The patient was alert when the paramedics arrived at the scene, but her level of consciousness declined en route to the hospital. The patient told the paramedics that she was not wearing a seatbelt and that she hit the windshield during the collision. On presentation the patient is drowsy but responsive to verbal commands. She complains of back and neck pain and a headache. There is a contusion and abrasion over her right temporal region; the remainder of her head, ear, eye, nose, and throat examination is normal. Neurological examination reveals no focal deficits, and that cranial nerves II-XII are intact. Vital signs, a CBC, and blood chemistry test results are within normal limits. A lateral x-ray of the cervical spine reveals no abnormalities. Non-contrast CT scan of the head shows a small skull fracture in the temporal region and an underlying extra-axial lenticular hyperdensity. Questions What is the most likely diagnosis? What is the etiology of this condition? What are the clinical manifestations of this condition?

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