case 42 – update 1

So we have a 47 year old gentleman. No past medical history. Works in telesales. He drinks 70 units of alcohol a week, for the last year. Doesn’t have a great diet, only occasionally eats vegetables. Lives alone, sees his 2 children at the weekend. Feeling low in mood over last year since his divorce.

No drug allergies, no regular medications.

2 month history of ‘memory problems’ poor concentration, problems at work remembering which part of the scripts he is reading.
Recently he has also had problems banging into things when he is walking.

He has no indigestion symptoms and no change in bowel habit.

Examination findings. MMSE 29/30. Slight left leg weakness 4+/5, power 5/5 elsewhere. Sensation normal. Some slowness in fine motor movements in left hand. No pass pointing on finger nose test, rhombergs negative. Cranial nerves intact. No evidence of papilloedema on non dilated fundoscopy. Chest clear, heart sounds normal.

Fbc

Hb 145

Mcv 102

Plt 155

Neuts 3.7

U+e normal

Lft – normal except GGT 150

B12 300

Folate 2.5

The patient has made an appointment to come back to the gp 7 days after the initial visit to get the results of the blood tests. 

The patient has been so worried that his drinking might have been causing problems that he has managed to cut down and stop drinking. When the patient arrives for the appointment he tells you that since waking up this morning his left arm has been weak.

Is there anything else you want to ask in the history? What is your differential diagnosis? If this patient was being seen in general practice how would you proceed?

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