Approach to differentiating lesions (cerebellum) Quiz: Ace Your Exams

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A 24-year-old woman presents to the primary care clinic for evaluation of chronic headaches. The headaches have gradually worsened in frequency, intensity, and severity despite trials of multiple migraine preventative medications. Head pain worsens with coughing, sneezing, and bending over. The patient reports difficulty swallowing for the past three months. There are no other medical problems and no regular medications aside from over-the-counter analgesics. There is no history of tobacco, alcohol, or illicit drug use. There is no family history of similar symptoms. Temperature is 37.0°C (98.6°F), pulse is 60/min, respirations are 15/min, and blood pressure is 110/70 mmHg. On exam, the patient appears to be swaying with down-beating nystagmus. There is decreased sensation over the shoulders and arms. Strength and reflexes are normal. Gait is slightly wide based. Which of the following diagnostic tests is most likely to confirm the diagnosis?

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Magnetic resonance imaging (MRI) of the brain and cervical spine without contrast

GAA trinucleotide repeat expansion analysis of the frataxin gene

Cerebrospinal fluid (CSF) paraneoplastic panel

CAG trinucleotide repeat expansion analysis of the ataxin-3 gene

Computerized tomography (CT) of the head without contrast