Case Challenge #16

The History

A 19 yo white male with no past medical history presents with hand tremors, slurred speech, and severe anxiety, all of which have progressed over the last 3 months. Present both at rest and with activity. Also notes a change in personality, characterized as “extremely anxious.” Initiated on anxiety medication without improvement. This has progressed to the point that anxiety has caused him to drop out of school. He comes in now with slurred speech, excess drooling, and difficulty walking. Denies visual changes, HA, Sz. No obvious wt loss. No fevers, chills, night sweats. No unusual travel or exposures.

  • Past medical/surgical history: none
  • Family history: grandfather with liver problem
  • Social history: no tobacco, alcohol, or drugs. Not sexually active. Lives at home. No pets.
  • Current Medications: alprazolam 1.75 mg at bedtime, citalopram 20mg daily

The Physical

  • Vital Signs: T 37.1, P 80, BP 140/75, RR 16, O2 sat 98% RA
  • Neurologic exam:
    • Awake and oriented x3
    • Tongue protruding; speech is slightly dysarthric; cranial nerves otherwise intact
    • Strength 5/5 in all extremities; tone increased in bilateral lower extremities
    • Fine hand tremor, increases with movement
    • Sensation intact
    • Deep tendon reflexes 2+ throughout
    • Romberg negative
    • Gait is wide-based, and spastic
  • Initial ocular exam not conducted
  • Remainder of exam is normal

The Labs

  • WBC 4, Hgb 14, Hct 40, plt 79 || BMP unremarkable, glucose 88
  • Albumin 2.5, INR 1.4
  • TSH normal

The Imaging

  • US abdomen: Nodular hepatic surface contour suggestive of cirrhosis

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