# Unsteady walking for two days in a 32-year-old: an ataxia case to work up

> A neurology case for medical students: a 32-year-old unsteady on her feet for two days after a cold. What to ask, red flags, how to examine balance and coordination, first tests and the differential.

- Neurology · Intermediate · about 20 minutes
- Web page: https://www.medikarya.in/case-studies/32-year-old-woman-with-unsteady-walking
- Work up this patient: https://www.medikarya.in/case-studies/32-year-old-woman-with-unsteady-walking

## How the patient presents

A 32-year-old mother of two comes to emergency because she has been unsteady on her feet for two days, worse at night and when she turns quickly. She had a cold about a week ago.

## Why unsteady walking matters

Unsteadiness can come from the cerebellum, the sensory nerves, the inner ear or weak legs, and each points somewhere different. A careful examination usually tells you which, and that decides how fast she needs imaging.

## What to ask in the history

- When it started and whether it is getting worse
- Worse in the dark or with eyes closed
- Spinning, hearing loss, ringing in the ears
- Double vision, slurred speech, trouble swallowing
- Numbness, weakness
- Headache, vomiting
- Recent infection or vaccination
- Alcohol, medicines
- Previous neurological episodes, such as loss of vision

## Red flags

- Sudden onset
- Severe headache or vomiting
- Drowsiness
- Double vision, swallowing difficulty
- Weakness that is spreading, or breathing difficulty
- Signs on one side only

## What to examine

- Gait, heel-to-toe walking, Romberg's test
- Eye movements and nystagmus
- Speech
- Finger-nose, heel-shin, rapid alternating movements
- Tone, power, reflexes
- Vibration and joint position sense
- Hearing, and the fundi

## First investigations

- Glucose, electrolytes, full blood count, vitamin B12
- MRI of the brain
- Further tests guided by the findings: lumbar puncture, nerve conduction studies
- Alcohol or drug levels if relevant

## Differential diagnosis of unsteady walking

Grouped, not ranked. Which one fits this patient is for you to work out in the case.

### Inner ear

- Vestibular neuritis
- Labyrinthitis

### Cerebellum

- Post-infectious cerebellitis
- Stroke
- Demyelination
- Alcohol or medicines
- Tumour

### Sensory nerves

- Inflammatory neuropathy and its variants
- Vitamin B12 deficiency

### Other

- Weakness
- Functional disorder

## Common mistakes

- Blaming the inner ear without testing for cerebellar signs.
- Skipping Romberg's test.
- Missing a stroke in the back of the brain because she is young.

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A study guide for medical students, not medical advice. Follow your institution's protocols in practice.