Medical Student Challenge #1 of 4

Can You Figure Out What is Wrong With This Patient?


Are you a medical student or a resident?  Or do you want to try to figure out the diagnosis? Below is a challenging patient case.  See if you can solve the case.  Send in your diagnosis to


A 64-year-old man arrives to the urgent care center at 2pm in the afternoon with his wife. He has a complaint of 2 days of intermittent dizziness. He has vomited 3 times in the past 2 days, but does not have any stomachaches and has not noticed any fevers.

When questioned in more detail, the patient describes intermittent right arm and right leg tingling for the past 2 - 3 days. His wife says that he does not demonstrate any unusual behavior, but that his speech has been occasionally slurred for the past 2 days.  He has not had any loss of consciousness, shortness of breath, chest pain, fevers, headaches, or diarrhea. He has not had any bladder problems, skin problems or rashes.


The patient has a history of hypertension and mild asthma and he does not generally get routine medical check ups. He has heartburn once in a while and takes an over the counter medication when he needs it. He has been a smoker for 40 years and he has a family history of Type 2 Diabetes, although he has never been personally evaluated for diabetes. He had several broken toes 13 years ago due to a fall while riding a motorcycle and he has some persistent discomfort of his foot and has experienced mild trouble walking since then.

He does not take any prescription medications or take any vitamins.


Your physical examination reveals a well-nourished appearing man who appears unsettled and is afraid to walk due to his dizziness. He is cooperative and is able to answer questions and provide a history of his symptoms and his overall health.

His skin appears normal. His throat appears normal. His heart rate and rhythm are normal. His pulses are slightly decreased, but palpable. His breathing is clear and normal. He does not have abdominal tenderness. He has a hoarse voice and occasional hiccups.

His neurological examination reveals the following:


He is alert and oriented x3.

His strength in the left and right upper extremities is normal.

His strength in the right upper and lower extremities is normal.

He demonstrates ataxia and dysmetria of his left upper and lower extremities.

He has normal sensation to touch on the right arm and right leg and slightly decreased pain and temperature sensation of the right arm and right leg.

He has normal sensation of the left arm and left leg.

He does not have any tremors or involuntary movements of his arms or legs.

His reflexes are slightly diminished on the right arm and right leg without upgoing toes.

His reflexes are normal on the left arm and left leg.

He has mild ptosis (droopy eyelid) of the left side.

He has normal pupils.

He has decreased sensation on the lower left left side of the face when compared to the right side of the face.

Sensation of the forehead is equal on both sides.

He exhibits bilateral nystagmus ( jerking side to side eye movements) when asked to look to either side.

He can try to walk, but he is unable to walk without supporting himself by holding on to a chair.


What do you think is wrong with this patient? Do you think you should order any diagnostic tests and, if so, which diagnostic tests?  The answer is found here.

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