A 79-year-old man with Parkinson disease for the past 3 years comes to the office due to poor appetite, weight loss, increased generalized weakness, "difficulty thinking," and impaired sleep over the past 4 months. The patient has become increasingly isolated as his functional abilities have declined and says, "I don't want to live like this anymore.
I hope God takes my life already." He is still able to live alone but has stopped
seeing his friends and no longer enjoys spending time with his family. The patient has no psychiatric history. He does not use tobacco or alcohol. His only medication is pramipexole. Temperature is 36.7 C (98 F), blood pressure is 144/88 mm Hg, pulse is 74/min, and respirations are 14/min. Examination shows right hand greater than left resting tremor; generalized muscle rigidity; and a slow, shuffling gait, none of which are new. On mental status examination, the patient's affect is blunted and his mood is depressed. He is oriented, states the months of the year backwards very slowly with 2 mistakes, and recalls 3 of 3 items in 5 minutes.

Educational objective: Major depressive disorder may occur in up to 20% of patients with Parkinson disease (PD). Although the diagnosis of major depression may be difficult due to overlapping symptoms with PD, the presence of depressed mood, anhedonia, hopelessness, and/or suicidality often suggests major depression.

Educational objective: Acute exacerbations of multiple sclerosis should be treated with high-dose intravenous glucocorticoids. Plasma exchange is reserved for patients who do not respond to high-dose glucocorticoids.

A 23-year-old woman with a history of anorexia nervosa is evaluated due to acute-onset confusion while hospitalized. Over the past 6 months, she has been severely restricting her caloric intake and has lost 7 kg (15.4 lb}. On adrnission, she was tachycardic and orthostatic, and her Blvll was 15 kg/m2. The patient has been receiving intravenous hydration and parenteral nutrition. Today, her family notes that she seems newly contused and unsteady when walking. Temperature is 36.7 C (98 F}, blood pressure is 110/70 mm Hg, and pulse is 86/min. She is not oriented to time or place. Bilateral pupils are equal and reactive. Her lateral gaze is restricted on both sides and evokes a horizontal nystagmus. There is no nuchal rigidity or motor weakness. Bilateral ankle reflexes are diminished. The patient walks slowly with short and wide-based steps.

Educational objective: Thiamine deficiency can cause Wernicke encephalopathy, which is characterized by encephalopathy, oculomotor dysfunction, and gait ataxia. This is generally seen in malnourished patients (eg, anorexia, chronic alcohol use) and may be induced iatrogenically by the administration of glucose without thiamine.

A 50-year-old woman is brought to the emergency department after suddenly developing right upper- and lower-extremity weakness while jogging on a treadmill. Her weakness gradually worsened over the next hour, and she started to experience severe headache, nausea, and vomiting. The patient has a history of chronic hypertension but stopped taking antihypertensives several months ago as she is "tired of taking medicine" and trying to "cure" herself with exercise. She does not use tobacco but drinks 1or2 glasses ot wme on weekends. Her blood pressure is 174/102 mm Hg and pulse is 76/min and regular. Neurologic examination shows right hemiplegia, right hemisensory loss, and leftward deviation of the eyes.

Educational objective: The basal ganglia (putamen) is a common site of hypertensive intraparenchymal brain hemorrhage. The internal capsule that lies adjacent to the putamen is almost always involved, leading to contralateral hemiparesis, contralateral sensory loss, and conjugate gaze deviation toward the side of the lesion.

A 54-year-old woman comes to the emergency department due to double vision and a droopy eyelid. The patient began seeing 2 side-by-side images while watching television last night She attributed the symptoms to tiredness and went to bed. The vision disturbance was persistent on wakinq up today, and the patient also found her right eyelid was drooping. The diplopia is worse when looking toward the left and is not associated with headache, nausea, dizziness, or focal weakness or numbness. Physical examination shows ptosis of the right eye. Adduction and upward gaze are impaired on the right side. Pupils are 2 mm on the left and 5 mm on the right, and both are reactive to light Examination of other cranial nerves is unremarkable. Upper and lower extremity strength, deep tendon reflexes, and sensation are normal. Noncontrast CT scan of the head is normal.

Educational objective: Non-pupil-sparing oculomotor nerve (CN Ill) palsies are concerning for aneurysmal compression. MR or CT angiography should be performed immediately. Pupil-sparing CN Ill palsies are most commonly caused by microvascular ischemia associated with diabetes mellitus, hypertension, and hyperlipidemia.

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