Neurological Case 79

Edward Roberts is a 68- year -old farmer who presents following a 2-week history of unsteadiness whilst walking, first noticed during a holiday in Amsterdam. His wife noticed that he seemed to be bumping into things. Mr Roberts commented that he did not see things as well on his right side. Over the past few days he has been having difficulties concentrating and feels that he is increasingly forgetful. He has also begun to experience a headache in the mornings which is worse when he coughs or sneezes. Mr Roberts’ past medical history includes hypertension and he also had a melanoma removed from the left side of his abdomen 3 years ago. On examination there is no evidence of lymphadenopathy.

His Mini - Mental State Examination score is 25/30 with defi cits in orientation and concentration. Examination of his fundi reveals blurring of his optic disc suggestive of papilloedema on the left. Visual fi eld testing reveals a right homonomous hemianopia. He has diffi culties walking in a straight line and does appear to bump into objects on his right. Mr Roberts’ scan demonstrates an abnormal lesion in the left occipital cortex with surrounding mass effect (Fig.26.1 ).