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A 57-year-old man comes to the ·office due to involuntary shaking of his hands It started on the right side, but now his left hand shakes as well. The shaking disappears with purposeful activity and worsens with emotional stress. He does not have a family history of tremors. Physical examination reveals a resting hand tremor with a frequency of 5-7 cycles/sec. There is some muscle rigidity of both arms. His gait and posture are normal. His mini mental status exam yields a score of 30/30.

Educational objective: Internuclear ophthalmoplegia is a disorder of conjugate horizontal gaze that results from damage to the medial longitudinal fasciculus (MLF). The affected eye (ipsilateral to the lesion) is unable to adduct and the contralateral eye abducts with nystaqmus. Unilateral MLF lesions can occur with lacunar stroke in the pontine artery distribution; however, bilateral lesions are classically seen in multiple sclerosis.

A 25-year-old woman comes to the office due to intermittent double vision, dizziness, and unsteady gait for the last several days. During the past year, she has had several episodes of numbness and dizziness, and her symptoms were attributed to anxiety. She does not use tobacco or alcohol. Her brother died of subarachnoid hemorrhage. Blood pressure is 130170 mm Hg and pulse is 76/min. On attempted left gaze, her left eye abducts and exhibits horizontal nystagmus, but her right eye remains stationary. When she attempts to look to the right, her right eye abducts and exhibits horizontal nystagmus, but her left eye remains stationary. The patient is able to converge both eyes without any associated nystagmus.

Educational objective: Meralgia paresthetica is caused by compression of the lateral femoral cutaneous nerve, typically due to tight belts or clothing. It presents with pain, paresthesias, or numbness limited to the lateral thigh without motor weakness. Risk factors include obesity, pregnancy, and diabetes mellitus. Management includes weight loss and avoidance of tight clothing.

A 56-year-old man comes to the ·office for evaluation of right leg pain and numbness. The pain started 2 days ago during an 8-hour car ride during which the patient was the backseat passenger in a small car. Midway through the car ride, he began to have numbness and burning pain over the lateral aspect of his right thigh. The patient has tried stretching to relieve the pain but it only worsened, and he is now unable to wear a belt due to the discomfort. He has type 2 diabetes mellitus and has gained 11.3 kg (25 lb) over the past year. BIVll is 42 kgfm2. On examination, lower extremity strength is 515 bilaterally. The right leg has a large area of numbness over the upper lateral thigh. Straight leg raise is negative. Reflexes are symmetrical and intact. Pain is reproduced on hip extension and with palpation immediately below the anterior superior iliac spine.

Educational objective: Acute exacerbations of multiple sclerosis with disabling neurologic symptoms are typically treated with glucocorticoids (eq, intravenous methylprednisolone). Plasmapheresis should be considered in patients who are refractory to corticosteroids.

A 38-year-old woman comes to the emergency department due to a 3-day history of left arm and leg numbness. She also reports urinary urgency and incontinence but has no fever or dysuria. The patient was diagnosed with multiple sclerosis 10 years ago after an episode of right eye vision loss. She was taking disease-modifying therapy but stopped after being symptom-free for several years. Temperature is 37 C (98.6 F), blood pressure is 130/80 mm Hg, and pulse is 88/min. Sensation to light touch and pin prick is diminished on the left side. Neuroimaging reveals new areas of demyelination compared to previous 11/IRls.

Educational objective: Neuromuscular junction disorders are generally characterized by muscle weakness in the absence of upper or lower motor neuron signs. lvlyasthenia gravis is a neuromuscular disease that typically presents with fluctuating and fatigable extraocular (eg, diplopia, ptosis) and bulbar (eg, dysarthria, dysphagia) muscle weakness as well as symmetrical proximal weakness of the neck and extremities (upper more than lower).

A 44-year-old woman comes to the office with muscle weakness over the past several months. She has difficulty combing her hair and, occasionally, difficulty holding up her head, particularly after prolonged sitting or standing. The patient has had no difficulty \'talking or getting up from a chair. She has also had 2 episodes of double vision while driving home from work. The patient takes rosuvastatin for hyperlipidemia and lisinopril for hypertension. Blood pressure is 142184 mm Hg and pulse is 76fmin. Neurologic examination shows mild right ptosis, symmetric proximal muscle weakness in the upper extremities, and weakness in the head extensors. Muscle bulk and tone are normal and there is no muscle tenderness.

Educational objective: Individuals with features of myasthenia gravis ( eg, fluctuating and fatigable ocularfbulbar weakness) should undergo confirmatory testing with acetylcholine receptor antibodies, which are highly specific. Those with an established diagnosis should subsequently undergo chest imaging (eg, CT scan, MRI) to evaluate for thymoma and for possible surgical planning, as thymectomy is associated with Jong-term clinical improvement in both patients with and without thymoma