Presentation of Case
A 26 year old male presents to the emergency with a 6-day
history of progressive difficulty walking, double
vision, and slurred speech. He complains of a mild diffuse
headache and reports paresthesias of the arms.
His wife reports that he is the fifth day of treatment with tetracycline for a genital ulcer.
He reports that recently experienced some cold
symptoms during the preceding week. There is no history of fever,
cough, chest pain, abdominal or urinary
symtoms. He denies allergies or past surgery.
- Physical examination reveals a well-developed, well nourished white man in no acute distress. His vital signs include a pulse of 90 bpm, blood pressure of 150X100 mmHg, respirations of 22/min and a temperature of 37 C.
The patient's skin was warm and dry and his extremities showed no cyanosis or edema
- Chest
- His lungs were clear upon auscultation and his heart rhythm is regular, with a normal first and second heart sound( S1 and S2) and no third or forth sound.
- Abdomen
- His abdomen was soft, without tenderness or obvious mass.
- Neurological Examination
- Higher Cortical Function - Altered only for slurred speech
- Gait and Stance - Ataxic gait and a Rhomberg's sign drifted to the left.
- Coordination - bilateral ataxic finger to nose movement without intention tremor
- Sensory System - Distal paresthesias and mild impairment of distal position and vibration sensation in the upper extremities.
- Motor System - Normal strengh and tone in lower limbs and a grade 3/5 strengh in upper limbs
- Reflex - Deep tendon reflex were absent in all limbs.
- Cranial Nerves - Diplopia and paralysis of the left abducent nerve
Now if you know the diagnosis you can confirm it without see the exams, but if
you want some help in each buttom you will find patient's exams and
diagnosis.