A 65-year-old man comes to the office due to unsteady gait and frequent falls over the past 2 months. His left side feels "weak," which makes it difficult to maintain balance when walking or standing. He has also had headaches and nausea, which are worse in the mornings before he has had coffee. The patient has a history of hypertension and type 2 diabetes mellitus, and he had a myocardial infarction 5 years ago. He takes insulin for diabetes mellitus but does not routinely monitor his blood glucose. The patient is a former smoker and does not use alcohol or illicit drugs. Blood pressure is 130/80 mm Hg and pulse is 76/min. Ambulation results in the patient swaying to the left and using the wall to brace himself. There is increased resistance to passive flexion of the left upper and lower extremity. Which of the following is the most likely cause of his current condition?

Question

A 65-year-old man comes to the office due to unsteady gait and frequent falls over the past 2 months.  His left side feels "weak," which makes it difficult to maintain balance when walking or standing.  He has also had headaches and nausea, which are worse in the mornings before he has had coffee.  The patient has a history of hypertension and type 2 diabetes mellitus, and he had a myocardial infarction 5 years ago.  He takes insulin for diabetes mellitus but does not routinely monitor his blood glucose.  The patient is a former smoker and does not use alcohol or illicit drugs.  Blood pressure is 130/80 mm Hg and pulse is 76/min.  Ambulation results in the patient swaying to the left and using the wall to brace himself.  There is increased resistance to passive flexion of the left upper and lower extremity.  Which of the following is the most likely cause of his current condition?

Quizplus · Accepted Answer

Explanation: This patient has gait dysfunction, headaches with nausea worse in the mornings, and focal left-sided weakness, raising concern for an intracranial tumor affecting the motor cortex. Brain tumors are often clinically silent until they grow large enough to compress neurologic structures or raise intracranial pressure (ICP). The most common symptom is a dull headache associated with >1 of the following: > Nausea and vomiting (due to increased ICP) Focal neurologic manifestations (due to tumor invasion or compression) Symptoms worsening during the night or with positions that raise ICP (eg, bending, coughing) Funduscopic examination showing papilledema, a sign of elevated ICP, supports the diagnosis. Patients usually require MRI of the brain for further evaluation. papilledema (Choice B) Diabetic polyneuropathy usually causes a sensory neuropathy of the lower extremity with diminished pain, touch, temperature, and vibratory sensation. Left-sided weakness and headache with nausea are not typically associated with this condition. (Choice C) A hemiplegic migraine usually causes a combination of neurologic findings and headache that last hours (not months) and resolve completely. Hemiplegic migraines are quite rare and typically occur in teenagers (not elderly patients). (Choice D) Lacunar infarctions are usually seen in patients with vascular disease risk factors and often cause unilateral weakness; however, 2 months of headaches and nausea would be atypical. (Choice E) Neuroglycopenia (hypoglycemia of the brain) can be associated with insulin use and result in transient nausea, headache, and focal neurological symptoms. However, this condition usually last minutes or hours, not 2 months. (Choice F) Normal-pressure hydrocephalus is caused by impaired cerebrospinal fluid absorption and usually causes shuffling gait, cognitive decline, and urinary incontinence. Unilateral weakness would be atypical. (Choice G) Parkinson disease is a progressive neurodegenerative disorder characterized by resting tremor, rigidity, and shuffling gait. (Choice H) Tabes dorsalis is a manifestation of neurosyphilis associated with sensory ataxia and lancinating pain. Unilateral weakness and headache with nausea would be uncommon. (Choice I) Vitamin B₁₂ deficiency typically presents with progressive symmetric paresthesias and sensory ataxia, not unilateral weakness. ₁₂ Educational objective: Patients with an intracranial mass often have headache associated with nausea and vomiting and/or focal neurologic deficits. Symptoms are often worse at night and with body positioning that increases intracranial pressure. An MRI of the brain is usually diagnostic. References: Clinical presentation, diagnosis, and pharmacotherapy of patients with primary brain tumors. (http://www.ncbi.nlm.nih.gov/pubmed/10466912) Headaches in patients with brain tumors: a study of 111 patients. (http://www.ncbi.nlm.nih.gov/pubmed/8414011) Headache as a symptom of ominous disease. What are the warning signals? (http://www.ncbi.nlm.nih.gov/pubmed/9158606) Brain tumor headaches: from bedside to bench. (http://www.ncbi.nlm.nih.gov/pubmed/20644433)

A 65-Year-Old Man Comes to the Office Due to Unsteady