Presenter: Tyler Reimschisel, MD Preceptor: Harvey Singer, MD


October 07, 2002

Case 1 Presentation

The patient is a 17-year-old young woman who presents with a 4-month history of progressive difficulties swallowing, speaking, writing, and seeing.

History of Present Illness

The patient's speech has been worsening progressively during the past 4 months. She slurs and mumbles words. Many people have commented that it is difficult to understand what she is saying. During the same period, her swallowing has also become progressively difficult. She has difficulty initiating a swallow, especially with liquids. Her swallowing difficulty is not diurnal. Over the past month, she has begun drooling. A swallowing evaluation performed at an outside institution was normal.

The patient also complains that her vision has steadily declined during this same time period. When she first noted blurring of her vision, she was evaluated by an optometrist, who diagnosed near-sightedness and prescribed corrective lenses. An ophthalmologist provided a second opinion and confirmed the diagnosis. No other abnormalities were identified.

The patient also reports that her handwriting has become particularly sloppy. Her teachers have told her that she needs to be more careful in her writing. Nonetheless, her writing has become so poor that she has not written for 2 months. Now she must type or dictate the answers to her homework. She has experienced 2 episodes of syncope. The first episode occurred while she was riding the subway; the second occurred while she was walking in a shopping mall. She did not experience dizziness or other changes before fainting. She also reports a 1-month history of intermittent vertigo that began as she was recovering from acute gastritis. The room consistently rotates from the left to right, and the vertigo is associated with nausea.

She has suffered chronic fatigue during the past 4 months, and her appetite has diminished. She wakes up early in the morning and has difficulty falling back to sleep. Her family and friends have commented that her facial expressions are flattened, and overall, she feels that her mood is depressed. She reports no problems with cognitive decline. In fact, since her symptoms began, her grades have improved because she goes out with her friends less frequently than before the onset of her medical problems.

She has experienced no recent head trauma or known toxin exposures; she has not received any new medications. She has no drug allergies


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