An Accountant Who Loves Aerobics With Hiccups and Incoordination

Ajith Goonetilleke, MB BS, FRCP


July 02, 2021

Physical Examination and Workup

Upon physical examination, the patient has an oral temperature of 98.6°F (37°C). Her pulse is regular with a rate of 86 beats/min. Her blood pressure is 164/90 mm Hg, and her heart sounds are normal and without added sounds. No arterial bruits are auscultated in her neck.

She is noted to have prolonged bouts of hiccuping. She is unable to stand due to a severe feeling of imbalance. Right-sided ptosis and miosis is observed. She has a sustained horizontal gaze-evoked nystagmus looking to the left and right, with a downbeating nystagmus on downward gaze. Decreased sensation of pinprick and temperature on the right side of the face is noted. The right side also has reduced movement of the palate, and the gag reflex is diminished. The tongue movements are normal.

The power is normal in all 4 limbs, the deep tendon reflexes are normal, and the plantar responses are downgoing bilaterally (no Babinski sign). Moderate ataxia affects the right arm and leg. Sensation to pinprick and temperature is decreased on the left arm, leg, and trunk. The joint position and vibration sense are intact bilaterally.

Routine laboratory analysis findings, including a complete blood cell count, a basic metabolic panel, and a lipid profile, are normal. Noncontrast CT scan of the head findings are normal. MRI of the brain is obtained (Figure 1).


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