A 54-year-old man with slowness of movement and confusion

Abstract

This patient’s history dated back to 1 year prior to presentation. He had acute pancreatitis of uncertain cause. He did not drink alcohol and no gallstones were identified. He did develop a pancreatic pseudocyst following which was followed by CT and thought to be diminishing in size. He was in his normal state of health prior to this with no significant past medical history. He became fatigued after the pancreatitis. His wife then noticed reduced facial expression and some confusion, such as misplacing his billfold and being unable to find it. Clear episodes of amnesia or memory loss were difficult to specify. He discontinued driving because of these problems and being bothered by the movements of cars and the car lights bothering his eyes. The patient reported slowness of movement, trouble with balance, rare twitching of muscles, and mild stooped posture, photosensitivity, mild lightheadedness on standing, and hypophonia. He reported increased startle and a few jerks occurring during sleep. He also reported a few screams at night but there was no strong suggestion of REM sleep behavior disorder. He denied tremors, micrographia, muscle stiffness, trouble with eye movements, neck stiffness, motor weakness, dysphagia, dysarthria, shuffling, reduced arm swing, involuntary wandering of arm or leg, excessive drooling, erectile dysfunction, tinnitus, tongue biting, anhidrosis, repeating himself, forgetfulness during mid-sentence, fluctuating cognition, difficulty falling asleep, trouble recognizing familiar faces, hallucinations, problems reading, writing, or spelling, problems with language, deja vu, loss of emotion, or behavioral dyscontrol. His past medical history was remarkable for hypertension, possible depression, and the episode of pancreatitis. His medications on presentation were venlafaxine 75 mg once daily and metoprolol 25 mg twice daily. He was a lifetime nonsmoker, did not drink alcohol, and had no history of illicit injection drug use or significant travel history. His paternal grandfather had …