Educational objective: Lateral medullary infarct (Wallenberg syndrome) occurs due to occlusion of the posterior inferior cerebellar or vertebral artery. Patients develop loss of pain and temperature over the ipsilateral face and contralateral body, ipsilateral bulbar muscle weakness, vestibulocerebellar impairment (eg, vertigo, nystagmus), and Horner's syndrome. Motor function of the face and body is typically spared.

A 67-year-old man comes to the clinic for the first time. He speaks and walks very slowly. The patient's chief symptom is "extreme forgetfulness" for the past 6 months and he fears he is developing "dementia like my father." He says, "I used to be a very bright and sharp person, but now I can't even concentrate to work or read a book or newspaper. I feel extremely low and useless." The patient tearfully shares that he has been losing sleep, has little energy, and recently took a leave of absence from work as he could no longer concentrate on details and complete his paperwork. Medical history is significant for hypertension, hypercholesterolemia, diabetes, benign prostatic hyperplasia, and transient ischemic attack. Family history is significant for hypertension and diabetes in his mother and Alzheimer disease in his father. He does not smoke and drinks wine only occasionally. The patient has lived alone for the last 6 months since his son moved out Physical examination is normal except for markedly slow movements. CT scan of the head is normal.

Educational objective: Elderly patients with depression often present with cognitive impairment that can mimic other causes of dementia. The impairment is usually reversible with treatment of the underlying depressive disorder.

A 63-year-old man is brought to the office by his daughter due to recurrent falls. According to his daughter, the patient has lost his balance and fallen several times over the past 6 months. He has not sustained serious injuries. She has also noticed some "shaking" of his right hand that is most apparent at rest The patient has lived alone since his wife died 5 years ago and still shops, cooks, and cleans independently. Blood pressure is 141/68 mm Hg and pulse is 72/min. Neurologic examination shows mild rigidity of the limb muscles that is most prominent on the right side with a slow, shuffling gait The patient is prescribed medication for his symptoms but returns to the office 4 weeks later reporting "disturbing visions of strangers creeping around corners of his apartment" On examination, he is alert and scores 27 /30 on the Montreal Cognitive Assessment (normal: ;::26).

Educational objective: Medications used in the treatment of Parkinson disease may cause hallucinations. Dopamine agonists and, to a lesser extent, levodopa are associated with this adverse effect

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A 58-year-old woman comes to the physician due to difficulty walking. Over the last several weeks she has also experienced bilateral foot numbness and tingling. She was diagnosed with advanced Hodgkin lymphoma 2 months ago and is currently undergoing chemotherapy containing bleomycin, doxorubicin, and vincristine. Her other medical problems include type 2 diabetes and hypertension. Physical examination shows bilateral weakness on dorsiflexion of the feet and loss of pain and temperature sensation affecting both toes. Knee jerk reflexes are 2+ bilaterally but ankle jerk reflexes are absent

Educational objective: Chemotherapy-induced peripheral neuropathy typically presents as a symmetric, distal, sensory neuropathy that spreads in a stocking-glove pattern. Common causative agents include platinum-based medications (eg, cisplatin}, taxanes (eg, paclitaxel), and Vinca alkaloids (eg, vincristine }.

A 71-year-old man comes to the ·office due to worsening low back pain. The patient is having significant pain with movement that is limiting his activity, as well as nocturnal pain that is disrupting his sleep. He has had no lower extremity weakness or numbness and no bladder or bowel dysfunction. He is taking ibuprofen 3-4 times a day, and it is not controlling his pain. The patient has a history of prostate cancer and takes leuprolide. He also received palliative radiotherapy for multiple lumbar spine metastases several months ago. Temperature is 37 C (98.6 F), blood pressure is 140/86 mm Hg, and pulse is 88/min. Lower extremity motor strength, deep tendon reflexes, and sensation are normal.

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