Medstudy Videos channel

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Educational objective: Elderly patients with depression often present with cognitive impairment that can mimic other causes of dementia. The impairment is usually reversible with treatment of the underlying depressive disorder.

A 67-year-old man comes to the clinic for the first time. He speaks and walks very slowly. The patient's chief symptom is "extreme forgetfulness" for the past 6 months and he fears he is developing "dementia like my father." He says, "I used to be a very bright and sharp person, but now I can't even concentrate to work or read a book or newspaper. I feel extremely low and useless." The patient tearfully shares that he has been losing sleep, has little energy, and recently took a leave of absence from work as he could no longer concentrate on details and complete his paperwork. Medical history is significant for hypertension, hypercholesterolemia, diabetes, benign prostatic hyperplasia, and transient ischemic attack. Family history is significant for hypertension and diabetes in his mother and Alzheimer disease in his father. He does not smoke and drinks wine only occasionally. The patient has lived alone for the last 6 months since his son moved out Physical examination is normal except for markedly slow movements. CT scan of the head is normal.

Educational objective: Lateral medullary infarct (Wallenberg syndrome) occurs due to occlusion of the posterior inferior cerebellar or vertebral artery. Patients develop loss of pain and temperature over the ipsilateral face and contralateral body, ipsilateral bulbar muscle weakness, vestibulocerebellar impairment (eg, vertigo, nystagmus), and Horner's syndrome. Motor function of the face and body is typically spared.

A 56-year-old man comes to the emergency department with severe dizziness, inability to walk, and stabbing pain on the right side of his face that started this morning. He has a history of diet-controlled type 2 diabetes mellitus, hypertension, and hyperlipidemia. His blood pressure is 144190 mm Hg and pulse is 92fn1in. The patient topples to the right when sitting without support. The left pupil is larger than the right, and there is reduced corneal reflex on the right directly but not consensually. There is partial ptosis of the right eye. Horizontal and rotational nystagmus is present His voice is hoarse. His gag reflex is diminished. There is loss of pain and temperature sensation in the right face and the left trunk and limbs.

Educational objective: Dystonias are involuntary muscle contractions that often involve the small muscles of the head and neck; oculogyric crisis results in a forced upward gaze deviation. Dystonias typically occur as extrapyramidal symptoms of a high-potency, first-generation antipsychotic (eg, haloperidol, fluphenazine). Management includes benztropine and diphenhydramine.

A 26-year-old man is brought to the emergency department by police after he was found disoriented and wandering on the street No medical history is available. The patient is agitated and violent but calms down after several doses of lorazepam and haloperidol. Physical examination reveals confusion and bilateral horizontal nystagmus but no other focal neurologic findings. There are abrasions on the lower extremities. Urine drug screen is positive for phencyclidine. The patient is hospitalized for observation. Several hours later, his agitation and confusion have improved, but he reports difficulty with his vision. Temperature is 37.1 C (98.8 F), blood pressure is 134/84 mm Hg, pulse is 88/min, and respirations are 16/min. On examination, both eyes are deviated superiorly, and extraocular movement is restricted. There is rigidity of the neck and upper extremities. Noncontrast CT scan of the head shows no intracranial hemorrhage.

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Educational objective: Cryptococcal meningoencephalitis is common in patients with advanced AIDS and generally manifests with signs of elevated intracranial pressure (ICP), including progressive headaches, nausea/vomiting, and confusion.In a minority of patients, elevated ICP compresses the 6th cranial nerve and results in diplopia and lateral gaze palsy. The diagnosis is generally made using lumbar puncture with CSF analysis and India ink stain or capsular polysaccharide antigen testing.

A 38-year-old man is brought to the emergency department due to confusion and double vision. His family reports that the patient did not feel well for the past several days due to headaches, nausea, and vomiting. Yesterday, he became progressively confused and experienced double vision. He has a history of HIV and does not take antiretroviral therapy consistently. Temperature is 38.2 C (100.7 F), blood pressure is 122/80 mm Hg, and pulse is 90/min. On physical examination, the patient appears lethargic and disoriented. Pupils are equal and reactive, but the left eye does not move laterally with leftward gaze. The rest of the neurologic examination is unremarkable. Skin examination shows scattered, small, umbilicated papules with surrounding erytherna. CT scan of the head reveals mildly enlarged ventricles but no hemorrhage, infarction, or mass lesions.

Educational objective: The upper face receives input from bilateral motor cortices. Lesions in the central nervous system typically cause unilateral lower facial weakness that spares the forehead whereas peripheral lesions (eg, Bell palsy) cause weakness that affects the entire side of the face. Bell palsy may also result in decreased eye lacrimation, hyperacusis, and reduced taste sensation over the anterior tongue.

A 68-year-old woman comes to the emergency department for evaluation of stroke-like symptoms. The patient says her face appeared "twisted" this morning but was normal when she went to bed last night Her brother recently had a stroke, and the patient was worried that she may also be having a stroke. The patient has a history of hypertension, hypertipidemia, and type 2 diabetes mellitus. Vital signs are within normal limits. Physical examination shows facial asymmetry with drooping of the left corner of the mouth and loss of the left nasolabial fold.