Help, I can’t feed myself!

Author: Melanie Dyer / Editor: Steve Corry-Bass / Codes: ELP3, NeuP6, PhP1, SLO1 / Published: 19/01/2021

A 46-year-old female presents to the Emergency Department as she is unable to walk on her own and keeps falling over.

She describes a 2-month history of worsening bilateral tremor to upper and lower limbs that was initially intermittent, but is now persistent and she is struggling to feed herself.  She also reports unsteadiness leading to multiple falls that day, lethargy and word finding difficulty. She denies any other systemic symptoms. i.e., fever, weight loss, night sweats, headaches, vomiting, no recent illnesses and no travel.

Her PMH consists of depression & a “kidney problem”. Medications include lithium, pregabalin, quetiapine, vortioxetine. She is a smoker with minimal alcohol intake. She had her lithium levels checked 1 month ago when they were “normal”.

On examination, she has a course resting tremor to both arms and legs with no improvement with action, fasciculation to both thighs, bilateral increased tone/rigidity that is more prominent in the distal joints, normal power and sensation, hyper-reflexive throughout and nystagmus on lateral gaze. Her observations are normal.