Neurology Case Challenge: Visual and Auditory Hallucinations in a Patient With Parkinson Disease

Lee Neilson, MD; Elena Cecilia Rosca, MD, PhD; Simu Mihaela, MD, PhD; Chirileanu Ruxanda Dana, MD, PhD

Disclosures

January 24, 2022

Physical Examination and Work-up

Upon physical examination, he appears well and has a temperature of 98.2°F (36.8°C), blood pressure of 130/77 mm Hg, and a regular pulse of 68 beats/min. The chest, cardiovascular, and abdominal examination findings are all normal. The neurologic examination shows the patient to be alert and oriented to person and place but not to time. He has some difficulty finding words to express himself and has impaired short-term memory (Mini Mental Status Examination = 25/30) as well as impaired concentration, as evidenced by losing his train of thought in the middle of a sentence. His affect is depressed and he has problems with executive function and visuospatial tasks.

Although his blink rate is reduced, the cranial nerve examination findings are otherwise unremarkable. The motor examination reveals mild rigidity at the neck in both arms, along with bradykinesia with finger taps, opening and closing of the hands, pronation-supination arm movement, and heel taps. Sensation, coordination, and reflex testing are unremarkable. Examination of the patient's gait shows a mildly hunched posture, shortened stride length, and postural instability.

The laboratory analysis, including a complete blood cell count, vitamin B12, folate, erythrocyte sedimentation rate, and liver, thyroid, and renal panels, is normal. His cholesterol is elevated at 248 mg/dL (reference range <200 mg/dL), but his high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglyceride levels are all normal. Serologic tests for syphilis and HIV infection are negative. The CT scan of the brain below shows scattered lacunar infarcts and mild cortical atrophy without ventricular dilatation.

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