A Neurology Clinic for evaluation paper

Only upon repeated insistence from her parents did 19-year-old Emily reluctantly agree to see a psychiatrist. Emily complained that her “pushy and overprotective” parents really “need to chill”. In contrast, her parents reported that Emily changed significantly two years ago when she started high school. Whereas she was a straight-A student throughout middle school and high school, she struggled significantly in 12th grade. Her parents tearfully disclosed that their daughter had become unproductive and oppositional, easy to anger, and seemed unable to tolerate any kind of frustration. They found small amounts of marijuana, Xanax, and prescription stimulants. The MRI displayed a clear lesion in the left frontal cortex, highly suggestive of the previous injury to that region. Upon further questioning about the crucial period in which she had changed so significantly, Emily admitted to being in a traffic accident with her boyfriend, Mark. Since Emily had little recollection of the incident and did not tell her parents about it at the time, Mark was contacted by the psychiatrist (with Emily’s permission). He reported that Emily hit her head in the dashboard of the car. She was not totally unconscious but very dazed. For about 3 hours she spoke very slowly, complained of a bad headache and was confused. For about 2 hours, Emily didn’t know where she was, what day it was, and when she had to get home. She also threw up twice. For several months, she experienced frequent headaches, confusion, and nausea.

3. Carmen is a 35-year-old white female. She came to a Neurology Clinic for evaluation of her long-term neurologic complaints. The patient relates that for many years she had noticed some significant changes in neurologic functions, particularly heat intolerance precipitating a stumbling gait and a tendency to fall. Her vision also seemed to change periodically over several years. Two months ago, the patient was working very hard and was under a lot of stress. Her neurologic condition worsened. At that time, she could not hold objects in her hands, had significant tremors and severe exhaustion. She also had several bad falls. Since that time, she had noticed arthralgia (joint pain) on the right and subsequently on the left side of her body. Then, the patient abruptly developed a right hemisensory deficit (loss of sensation on 1 side of her body) after several days of work. An MRI revealed scar tissue in the white matter of the cerebral cortex in both hemispheres. Today, the patient has multiple problems related to her disease: she remains weak and numb on the right side. Carmen has impaired urinary bladder function and has become incontinent.  She also has persistent balance problems with some sensation of spinning, and she is extremely fatigued.

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4. Morgan, a 15-year-old adolescent, is brought to a neurological clinic, due to episodes of “blanking out” which began a month ago. During these episodes, she abruptly stops all activity for about 10 seconds, followed by a rapid return to consciousness. Morgan’s eyes are open during the episodes; and she remains motionless with occasional “fumbling” hand movements. After the episodes, Morgan assumes whatever activity she was previously engaged in with no awareness that anything had occurred. She has about 20 to 30 episodes a day.

5. Jacques is a 55-year-old man with chronic heart failure, moderate arterial hypertension, who has a recent history of blood clots forming in the heart’s left atrial appendage. He was admitted to a department of Neurology as an emergency due to sudden onset of lightheadedness, followed by a severe “thunderclap” headache. Jacques experienced disorientation, severe vertigo accompanied by impaired balance and disturbed vision, gait difficulties and nausea. The patient was referred to an urgent non-contrast brain CT, which found _____.

6. Living in an old, run-down apartment at a small mining town that has a water system in great disrepair, 6-year-old Emma is beginning to show symptoms that has her parents very worried. She displays delays in language development, problems with attention and impulse control (ADHD), mild hearing loss and a low score in an intelligence scale. Her mother reports to the doctor that pregnancy was normal and no genetic conditions were noted during genetic testing. She also reports that Emma does not have a medical history of high fevers, head injuries, infections or tumors. After seeing many patients like Emma, the doctor recommends doing a CT scan and especially blood work. What does he suspect is the cause of Emma’s symptoms?

7. Jake is a 59-year-old philosophy professor at a state university. In a Neurological appointment, he complained that for the last few years, his hands presented mild uncontrollable tremors while resting. When he was moving around, Jake noted that his leg muscles felt very stiff and he had many muscle pains and aches. Even though he used to love to jog, his speed while walking was much slower than usual. His penmanship had changed, he struggled to type his lecture notes and he started to whisper and mumble, while lecturing, much to his students’ annoyance. To make matters worse, Jake indicated that he occasionally felt “like in a fog”, unable to think quickly, when his students asked him a question (I can’t relate with this symptom at all 😉). Jake also complained of sleeping problems, constipation and some problems controlling his bladder, resulting in near misses getting to the bathroom.

8. Asha, a 21-year-old business major, was taken by ambulance to the neighborhood hospital when her roommate noticed some severe symptoms. At first, Asha had flu-like symptoms, that she treated with some medicines, chicken soup and sleep. However, she became very worried when she developed a high fever, very painful headaches, sensitivity to light, significant fatigue, muscle weakness and loss of sensations in her extremities. What caused her roommate to call the ambulance, was Asha’s agitation, confusion and visual hallucinations, which developed after a momentary loss of consciousness.

9. In July 2011, Colts’ tight end, John Mackey, died after experiencing debilitating symptoms. John displayed a progressive deterioration of executive functions, including memory loss, confusion, poor reasoning and problem-solving skills as well as problems with word finding. He also presented poor impulse control, resulting in aggressive outbursts. During his football career, John Mackey would frequently “plow through” the opposing team at full speed, resulting in many concussions.

10. Piri, a retired literature professor and theater director, showed symptoms of dementia as well as tremors, ataxia and visual hallucinations. The deterioration of executive functions progressed very quickly. In less than 4 years, Piri’s reasoning, language skills, motor activity were severely impacted. Piri changed from a vibrant and energetic writer to an almost non-responsive and bedridden patient, who had difficulty swallowing solid foods.

11. Andres is a 64-year old veteran, who started to present motor problems 3 years before. His complains included being clumsy, falling down, feeling weak, dropping things and difficulty with daily chores and especially writing. As time progressed, his symptoms worsened. In his last visit to the neurologist, Andres presented severely impaired speech, difficulty breathing, requiring a tracheostomy with oxygen and a feeding tube because of his difficulty swallowing. He was wheelchair-bound. Andres appeared frequently confused, presenting some symptoms of dementia.

12. A James, a15-year-old boy, while eating breakfast, suddenly flung his orange juice into the air, cried out loudly, lost consciousness and presented repetitive episodes of muscle rigidity and tremors. He previously was healthy, although his family described him as ‘‘clumsy,’’ especially in the mornings, wherein he “dropped things all the time”. Further questioning revealed that his clumsiness was associated with sudden jerks of his arms. The initial evaluation, including neurologic examination, blood tests, and MRI scan, was unrevealing. Past history also was unremarkable, although he reported not liking bright lights and feeling ‘‘queasy’’ recently while playing video games. An EEG was described as abnormal, with a ‘‘photoparoxysmal response’’ involving sudden bursts of synchronous high-amplitude spikes when a strobe light was turned on at a flash rate of 16 per second.

List of Possible Diagnoses:

Cerebral Thrombosis


Traumatic Brain Injury

Major Depressive Disorder

Chronic Traumatic Encephalopathy


Neurotoxin – Lead or Neurotoxin – Mercury

Absence Seizures

Tonic Clonic Seizures

Amyotrophic Lateral Sclerosis (ALS)

Parkinson’s Disease

Multiple Sclerosis

Lewy Bodies Dementia

Alzheimer’s Dementia

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