Neurology

For the past week, a 16-year-old boy has had a progressively worsening dry, irritating cough; dyspnea on exertion; and intermittent fever and chills. During the past 24 hours, he has had no appetite and has vomited greenish material 3 or 4 times.

A 30-year-old woman complains that her headaches no longer respond to triptans; instead, they have increased in frequencyand severity. The pain interferes with her ability to work part-time and to take care of her 16-month-old daughter.

A 46-year-old man presents with right-sided facial paralysis. His symptoms beganthe previous evening when he had difficulty in closing his right eye; by morning,paralysis had developed. He also reports headache and mild photophobia.

We chose to present this case to readersbecause the patient’s neurologicexamination was normal and her presentationthus appeared benign.

What is the risk of dementia in patients who have had an ischemic stroke?

A 23-year-old man presents to the emergency department with fever, headache,and photophobia. His illness began 5 days earlier with malaise, followed byfever, prostration, nausea, and vomiting. After 3 days, a severe headache developed,accompanied by photophobia; the headache did not respond to over-thecounteranalgesics.

An 81-year-old man presents with severe Alzheimer dementia. Hishistory includes benign prostatic hypertrophy with 2 transurethralresections. He has a remote history of tobacco use and has not used alcohol excessively. He isotherwise in good health. At the time of his original diagnosis, a cholinesterase inhibitor was notprescribed.

A 37-year-old man found unresponsiveat home with erratic respiration andurinary incontinence was brought tothe emergency department (ED). Accordingto his family, the patient hadbeen complaining of headaches, vertigo,and mild neck pain for 2 months.During that time, a CT scan of thesinuses revealed chronic sinusitis; thepatient had completed a course ofprednisone, naproxen, and meclizinewithout symptomatic improvement.The day before he was brought to theED, he had presented to a differenthospital with the same complaints andwas given a prescription for antibioticsfor a presumed sinus infection. He haddiet-controlled hypercholesterolemiaand did not smoke.

In the first case study featured in the article by Drs Jagoda and Riggio, “WhatYou Forgot About the Neurologic Exam, Part 1: History, Mental Status,Cranial Nerves” (CONSULTANT, December 2004, page 1773), a 46-year-oldwoman with a history of migraine presented with a bilateral headache thatradiated to the occiput.

A 74-year-old man comes to your office because his wife and childrenhave noticed that his memory has become mildly impaired. He continuesto work part time in the family business. Recently, however, his daughter has found thathe is making significant errors with clients. For example, he has failed to show up for appointmentsthat he had scheduled, and has set up appointments with clients whom he has already served.Because of errors he has made in client billing, he has turned over the company’s bookkeepingresponsibilities to his daughter.

A 27-year-old woman is hospitalized after laboratory studies revealed extremelyelevated liver enzyme levels. The studies were ordered after the patient soughtmedical attention for severe headaches that began 3 weeks earlier and for thepast several days had been accompanied by malaise, nausea, and vomiting.

A 12-year-old boy complains of severe weekly headaches that last 2 to 3 hours. The pain involves both sides ofthe head and the frontal and occipital areas. Occasionally during a headache, the patient complains of some abdominaldiscomfort and pain. He becomes passive and irritable during the headache; he does not want to be aroundpeople, play, or even watch TV. The patient’s parents note that a few hours before a headache, he becomes somewhatrestless and agitated. The headaches started about 1 year earlier, and the headache pattern (frequency, duration,location of pain, and associated symptoms) has not changed since that time. The patient’s mother and maternalgrandmother suffer from migraine.

A 30-year-old woman complains that her headaches no longer respond to triptans; instead, they have increased in frequencyand severity. The pain interferes with her ability to work part-time and to take care of her 16-month-old daughter.About 12 years earlier, the patient started having migraine headaches. She had no significant medical history, norwas there any obvious precipitating event. Typically, she had 1 or 2 debilitating headaches a month. These were accompaniedby photophobia, nausea, and vomiting-but not by auras. Oral triptans usually relieved the pain and associatedsymptoms within 1 hour.

Acamprosate calcium (Campral)from Lipha Pharmaceuticals, Inc,has been approved by the FDAfor the treatment of alcohol-dependentpersons who wish to remain alcohol-free after they have stoppeddrinking. Although its mechanismof action is not fully understood,this drug was shown to be more effectivethan placebo in maintainingabstinence. Acamprosate is nonaddictiveand has been shown to bewell tolerated in clinical trials. Themost common adverse effects areheadache, diarrhea, flatulence, andnausea.

A 72-year-old farmer is brought by his daughter for a comprehensivegeriatric assessment. His previous history is unremarkable. The patientreports that he has had vivid visual hallucinations, which he calls "visitors." He becomes frightenedand hostile when these incidents occur; on several occasions, he has exhibited violent behavioras persons around him tried to calm him. Although the patient was able to recall each episode indetail, he felt as if he had watched it from a distance and had not been an active participant.

Elderly patients with Alzheimer diseaseor dementia frequently refuseto be examined or have a physical.

A 53-year-old woman, who has a remote history of acne, says that facial rednessappears each time she has a migraine. Her migraine medication, fiorinalwith codeine, ameliorates the headache, but the erythema lingers for days.

Primary care doctor: Because of the patient’s age and theabsence of a headache history, I first considered such secondarycauses as tumor and temporal arteritis. However,MRI of the brain and erythrocyte sedimentation rate werenormal. I now suspect a sleep-related headache becausethe attacks occur only at night and awaken the patientfrom a sound sleep. How can I determine which type ofsleep-related headache is involved?

For 2 weeks, a 58-year-old woman has experienced increasingfatigue with activity. She has needed to nap duringthe day, has not been able to perform her usual activities,and has missed 3 days of work. She also complains of“muscle aches”-mainly in her back. She denies headache,dyspnea, fever, hot or cold intolerance, and alteredmentation.

Clinician: The patient’s symptom profile is confusing, especiallybecause his test results are normal. Are his amnesicepisodes related to his migraine?

A 32-year-old woman is admitted to the hospital because of nausea, vomiting,and mild jaundice. For 4 days, her health has steadily deteriorated: hepatictransaminase and bilirubin levels are elevated, prothrombin time is prolongedand, most recently, obtundation and changes in mentation have developed.Serologic studies for infection with hepatitis A, B, and C viruses are negative,as are tests for Epstein-Barr virus mononucleosis.

An 81-year-old woman is hospitalizedwith localized nonradiating low backpain of 3 weeks’ duration. She has nohistory of trauma, weakness of the legs,or urinary or bowel incontinence.

Which of these scenarios is familiarto you? •A local pharmacist calls to say thatyour patient wants another refill for thecombination analgesic containing aspirin,caffeine, and butalbital that youprescribed last week. Pharmacy recordsindicate that this patient has received250 tablets of this medication inthe last 34 days.

Q:Recent research has defined mild cognitiveimpairment as a transitional state between thecognitive changes of normal aging and Alzheimerdisease (AD) and other dementing illnesses. Whatcriteria are used to differentiate mild cognitiveimpairment from more innocuous syndromes, such asbenign senescent forgetfulness? Are patients with mildcognitive impairment considered to have incipientclinical AD?

A 60-year-old man has had anterior neck discomfort for the pastseveral weeks. He also has right-sided cephalalgia and occasional jaw discomfortwhile eating but no dysphagia or odynophagia. The cephalalgia, which hasbeen present for the past week, is moderately severe and is associated withblurred vision.