Ms. D, age 53 years, had a history of depression, peptic ulcer disease, and alcoholism. For several months, she had complained of fatigue and daily bifrontal headaches. She was referred to a neurologist after a brain MRI showed questionable white-matter changes. However, when Ms. D’s fatigue dramatically worsened, she returned to our primary-care clinic for further evaluation.

1. Presentation

The patient presented several months after the MRI with complaints of worsening fatigue and persistent headaches. Within the previous two weeks, Ms. D and her husband had also noted slurred speech, hypersomnia (17-18 hours/day), and memory lapses. Recollection of certain conversations and dates was lacking. She felt very weak and was having difficulty getting around the house. Moreover, she could not walk a straight line and felt significantly uncoordinated. The patient’s vision was poorer than usual but there was no diplopia. She reported photophobia (particularly during the headaches) but no scintillation.

Ms. D had suffered from depression for several years and was being treated with sertraline 100 mg daily to moderate benefit. When questioned about her depression, she responded, “It’s always there.” She denied suicidal or homicidal ideation and had no hallucinations.

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The patient reported no weight loss, fever, or chills. She had no complaints of chest or abdominal discomfort. There was no cough or hemoptysis. Ms. D denied any change in bowel or urinary habits. She reported generalized weakness but no specific joint or muscle pain.


2. Social history

Ms. D’s husband accompanied her to the office visit and contributed to the history. He confirmed the slurring of speech, increased lethargy, and dyscoordination. The younger of the couple’s two children had begun attending school full-time approximately three months previously, which Ms. D admitted was contributing to her increased depression. The patient recently missed several days of work because of fatigue. She reported no use of illicit drugs or tobacco, but further questioning revealed a history of alcoholism. When asked directly if she had recently started drinking again, she responded “yes.”

Ms. D had no preferred drink of choice and was unable to quantify the amount of alcohol she consumed daily. According to her, once she started drinking, she just could not stop. Her drinking binges might last several days. The last time she consumed an alcoholic beverage was five days prior to this primary-care visit. Ms. D was hospitalized 10 years ago for acute alcoholic withdrawal symptoms complicated by hallucinations.


3. Examination

The patient was a tall, thin white female in no acute distress. BP was 102/78 mm Hg, pulse 90 beats per minute and regular, and respiratory rate 16 breaths per minute. Her neck was supple and without lymphadenopathy, mass, or thyromegaly. No jugular venous distension was appreciated. Lung and heart exams were normal. Abdominal inspection revealed no distension, and bowel sounds were normoactive. Percussion was tympanic throughout. Palpation revealed a soft abdomen without mass or tenderness. The liver was not appreciably enlarged, and there was no splenomegaly. No costovertebral angle tenderness was detected.

On neurologic examination, Ms. D was somewhat lethargic but oriented to person, place, and time. Cranial nerves were grossly intact. Nystagmus was present on lateral gaze (more pronounced to the left). No papilledema was noted. Deep tendon reflexes were somewhat hypoactive throughout (1+). The patient’s speech was mildly slurred and slow. Results of a mental status exam were as follows: Three-word recall was intact at one minute, but only two of the three words were recalled at five minutes; naming of past presidents was successful to George H.W. Bush; backward spelling of “world” was incorrect; serial 7s were intact to 93.

No facial droop was noted. Motor strength was 5/5 with normal tone. Tandem walk was severely inhibited, and general ataxia was noted. Nose-to-finger exercise was within normal limits. Asterixis (flapping motion of outstretched, dorsiflexed hands) was present.