1997 Exam II Case 03
Chief Complaint:
This is a 66 year-old male with rapid onset of weakness and loss of communication.
History of Chief Complaint:
He experienced a severe bifrontal headache and lost the strength in his arm. He also lost his ability to communicate. He and his wife presented at the emergency room and he was admitted.
Medical History:
Acute rheumatic fever at age 5 with mitral regurgitation. Mitral valve prolapse at 58 and replacement at age 61.
Physical Exam: (Three weeks post stroke)
Blood pressure 140/88, respiratory rate is 18, heart rate is 80. Neck is supple without jugular vein distention. No carotid bruits are heard. Breath sounds are full and lungs are clear to auscultation and percussion. Heart has a regular rate and rhythm with a systolic click. Pulses are intact bilaterally in both extremities.
Neurologic Exam: (Three weeks post stroke)
Mental Status: He is an awake, alert individual in much distress. He is incapable of coherent speech. His speech is slow, low in volume and telegraphic in sound. He does not form recognizable words. He occasionally says "yes" or "no" to a question but cannot elaborate. Frequently he will produce a syllable of a word and then repeat that syllable several times unable to complete the word. He has no ability to repeat any words or phrases. He does understand spoken and written language and can follow 2 and 3 step commands with his right hand.
Cranial Nerves: His visual fields are full to confrontation and both pupils are reactive to light. At rest his eyes are positioned to the left and he cannot look to the right of midline. Warm water placed in his right ear causes his eyes to drift to the right of midline. He responds to touch and pin- prick throughout his face. His corneal and gag reflexes are intact. His face is asymmetric; the right corner of his mouth does not move in attempted speech or when attempting to smile or grimace. He is not drooling from the mouth. His forehead wrinkles symmetrically on upward gaze and both eyebrows elevate symmetrically. His palette elevates on the midline and his tongue protrudes on the midline.
Motor Exam: His strength is 5/5 in the left extremities and in the right knee and ankle. The right thigh is 3/5 in flexion and extension and the shoulder and elbow are 2/5 and the wrist and fingers 0/5. At rest his elbow is bent at 95¯ and the arm rests on his lap. The right arm is very resistant to passive range of motion. If forced into flexion, it suddenly gives way flexing fully, but returns to the 95¯ position when released. He can ambulate, however he has to swing his right hip forward to move the leg due to the weakness of the thigh flexors. There are no adventitious movements. He can move the left arm spontaneously. However, he cannot volitionally demonstrate a "wave goodbye", nor can he demonstrate how to use a hammer, saw or screwdriver with the left arm.
Reflexes: Deep tendon reflexes are 2/4 in the left extremities and at the right ankle. In the rest of the right extremities, deep tendon reflexes are 3/4 at the knee, 4/4 at the biceps, triceps and brachioradialis.
Sensory: He is responsive to touch and pin prick throughout his body and extremities. All four extremities have position sense except for the wrist and hand on the right.
Follow Up:
Examination one year later finds the almost complete resolution of the speech defect. His power in the right arm is 5/5 at the shoulder and elbow and 4/5 at the wrist and hand. Deep tendon reflexes in the right arm are 3/5 at the biceps, triceps and brachioradialis. Although he has normal power and reflexes on the left, he still has some difficulty demonstrating common movements with the left arm. His wife reports that he is making inappropriate remarks and does not take as much interest in their grandchildren as he did prior to the stroke. He seems unable to complete even small tasks around the house that he previously enjoyed doing.
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Number: 1 The weakness in the upper extremity of this patient is most likely due to a lesion of the:
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Number: 2 The language deficit expressed in this patient is best described as:
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Number: 3 The sensory loss expressed in this patient is most likely due to a lesion of the:
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Number: 4 The defect in eye movement expressed in this patient is best described as:
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Number: 5 The defect in eye movement expressed in this patient is most likely due to a lesion of the:
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Number: 6 The inability to demonstrate common movements in this patient's left arm is best termed:
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Number: 7 The inability of this patient to demonstrate common movements with his left arm most likely results from a lesion of the:
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Number: 8 The personality changes in this gentleman, one year after the lesion, are most likely due to damage to the:
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Number: 9 Of the following locations in this patient, degenerating axons will most likely be present in the:
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Number: 10 Of the following locations in this patient, chomatolytic cell bodies will most likely be present in the:
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Number: 11 The best description of the distribution of this lesion is:
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Number: 12 The best description of the temporal profile of the pathology in this lesion is:
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Number: 13 Imaging studies of this patient would most like demonstrate an occlusion occurring in the territory of the:
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