1997 Exam II Case 01

Chief Complaint:

This is a 65-year-old woman with sudden onset of dizziness, weakness and uncontrolled movements.

History of Chief Complaint:

She had complained of periods of dizziness over the past 18 days and recently had experienced at least one bout of dizziness that caused her to fall down in a local department store. On the day of admission she experienced the rapid onset of dizziness, loss of balance, weakness in her left arm and leg and uncontrolled movements in her left extremities.

Physical Exam:

This is a well nourished 65-year-old woman who appears her stated age. Facial expressions are very mildly asymmetrical around the left corner of her mouth. Facial skin is dry on the right and moist on the left. Her skin throughout her body is supple and moist. She denies dysphagia, dysphonia or dyspnea. Vertebral bruits are present over the cervical spinal column.

Neurologic Exam:

Mental status: This is an awake, oriented 65 year old woman who is well aware of her situation. Her fund of knowledge and memory are intact. She is capable of following three-step commands. She can spell the word W-O-R-L-D backwards. Her speech is meaningful and well articulated.

Cranial nerves: She has a full range of eye movements, however, there is a vertical, upbeating nystagmus on forward gaze that intensifies on upward gaze. Pupils are 3.5 mm on the left and 2 mm on the right. Pupillary reflexes are reactive to light both direct and consensual, however, the left pupillary reflex is more pronounced than the right. Both eyes open, however, the left eye opens to 20 mm and the right eye opens to 25 mm. Visual fields are full to confrontation. She is responsive to pin-prick throughout her face. There is a mild suggestion of paresis in the left corner of her mouth. Corneal and gag reflexes are intact. Both eyes close tightly and her forehead wrinkles symmetrically on upward gaze. Her palette elevates symmetrically, uvula is on the midline and tongue protrudes on the midline. Both shoulders elevate symmetrically.

Motor exam: Her power is 4/5 in the upper and lower extremity on the left and 5/5 in the right extremities. The left upper and lower extremity demonstrates past pointing on finger-to-nose and heel-to-shin testing. The left hand can not keep pace with the right on testing for rapid alternating movements. When stimulated by touch or occasionally during purposeful movements, the left extremities are interrupted by purposeless, random jerky movements that the patient tried to hide or convert into a more purposeful movement. She could not walk due to the dysmetria in her left leg, attempts to do so end in her falling to the left. Attempts to sit up in bed also ended in her falling to the left consequent to dysmetria in the trunk muscles.

Reflexes: Deep tendon reflexes are 2/4 at the wrist, elbow, ankle and knee on the right and 3/4 about the wrist, elbow, ankle and knee on the left.

Sensory: All sensory modalities are intact in the right extremities and body. Examination of the left extremities and body finds mild reduction in two point discrimination and vibratory sense. Sensation to pin-prick is blunted on the left side of her body and left extremities. Position sense is normal throughout the left extremities.

Follow-Up

A neurologic examination at 3 weeks post-event finds her nystagmus and dizziness and her facial asymmetry resolved. Her power is now 5/5 and symmetric in all extremities. The random purposeless movements in her left extremities have ceased. She has, however, a residual dysmetria in the upper and lower extremities on the left. Her truncal instability has cleared, but the dysmetria in her left leg still causes her to stumble slightly when walking and to veer to the left. She can ambulate comfortably with the assistance of a cane.

Questions

INSTRUCTIONS: Provide the BEST or MOST LIKELY answer to the following multiple choice questions.