Harry is in his mid-40s. He has come to his doctor reporting general weakness, particularly in his lower extremities. When he enters the doctor’s office, he is obviously clumsy (“Gee, I guess I shouldn’t have that third martini at lunch,” he jokes). However, the physician’s assistant (PA) who takes him back to the examination room notices that his speech is slurred.
In taking his medical history, the PA notes that Harry has had a six-month-long problem with extreme fatigue and he has lost significant weight. In fact, his upper body appears to have nearly wasted away. When asked why he came in, Harry tells the PA that he has had difficulty in combing his hair, writing, climbing stairs, and climbing up and down out of his truck. His arms have become increasingly weak, and he has also experienced increasing trouble getting dressed (zipping and buttoning his jeans is beyond him).
As the PA speaks with Harry, he notices that Harry’s tongue is moving strangely; it keeps writhing and twitching. During the physical examination, Harry gags on the tongue depressor (when it is only touching his lips!) and he has difficulty swallowing. He also shows an abnormal Babinski reflex: his toes fan out when the bottom of his foot is stroked. While the remainder of his reflexes is normal, Harry shows pronounced muscle weakness and abnormal spasticity—mostly in his legs, but also in his arms, though to a lesser degree.
Based on the report from his PA, the doctor decides to order a series of tests, including an MRI and EMG. While the MRI comes back normal, the EMG is quite abnormal; it indicates denervation. A blood test indicates an abnormally high level of glutamate.
In discussing treatment options, the doctor admits that the prognosis is not good. However, he does recommend the following: (1) a prescription for Baclofen and Riluzole to alleviate symptoms; and (2) physical therapy, and potentially speech and occupational therapy later on.
Questions
- What condition or conditions (there may be more than one possibility) are being described in this case? Does this involve brain damage, a specific disease or disorder, or some other condition that may be affecting the patient’s ability to move?
- What brain area or area(s) may be involved? How should they function normally? What could be causing this dysfunction?
- How would the treatments recommended affect the brain? How might those effects relate to the symptoms?
- How can you explain all of the symptoms exhibited by this case? Can you relate each symptom to a specific brain area or neurotransmitter?
- What other interventions may be possible, besides those noted here?
Remember to document your sources!
Originally published at http://www.sciencecases.org/mini_movement/2harry.asp
Copyright © 1999–2010 by the National Center for Case Study Teaching in Science. Please see our usage guidelines, which outline our policy concerning permissible reproduction of this work.
