This is a 67-year-old right-handed male with sudden onset of confusion, weakness and loss of communication.
History of Chief Complaint:
He was returning from the winter in Florida with his wife. They had spent the day driving north and stopped for the night in a motel in Virginia. He awoke the next morning unable to communicate clearly and confused as to where he was located. His wife drove him to the emergency room of a local hospital where he was admitted. After stabilization, he was transferred to a hospital in Massachusetts for three weeks and then discharged. A follow-up evaluation for rehabilitation was done at six weeks poststroke.
Medical History:
He was diagnosed with hypertension 10 years previously. He has been controlled by the diuretic bumetanide. Surgical History: none Allergies: none Medications: Bumetanide Physical Exam: This is a 76 year-old right-handed, well nourished male who appears confused and disoriented. His blood pressure is 160/90 mmHg and his pulse is 90 beats minute. His respirations are 16 and his temperature 98.5øF. His peripheral pulses are intact at the ankles and wrists. He does not appear to have any dysphagia or dyspnea. Bladder and bowel functions are intact.
Neurologic Exam:
Mental status: He knows his name but is disoriented for time and place. He did not know why he was in the hospital but did not offer confabulated explanations even when prompted. He could not count to ten by himself and did not know how many nickels there were in a dollar when asked. His speech is sparce, having many paraphasic errors. He often perseverated on a word or phrase, repeating it 5 or 6 times over. However, he could repeat complex phrases following the examiners lead. He could demonstrate a smile or frown with his face but never smiled, laughed or frowned spontaneously. When asked, he would report that he felt sadness but it did not show in his facial expressions. His wife reported that previous to the stroke, he frequently laughed and joked when happy and would pout and even cry when sad.
Cranial nerves: He has full range of eye movement and both pupils respond to light. Visual fields are intact on the left, but he is unable to see objects presented in the right visual field. This loss extended throughout the entire right visual hemisphere up to the vertical midline. There is no suggestion of macular sparing with his visual loss. He seemed to be aware of this visual loss and appeared upset by it. He seemed aware of stimuli in all parts of his face and reacted to pin-prick throughout his face. Corneal and jaw-jerk reflexes are intact. Movement of facial muscles is intact but he does not change facial expression spontaneously. Hearing to finger rub is intact at both ears. He can chew and swallow dry foods. Both shoulders elevate symmetrically and his palette and tongue function on the midline.
Motor exam: His power is 5/5 in the left arm and leg and 4/5 in the right arm and leg. There are no adventitious movements in any extremity.
Reflexes: Deep tendon reflexes are 2/4 at the ankle and biceps on the left and 3/4 at the ankle and biceps on the right.
Sensory: He seemed aware of all types of sensory stimuli throughout his body and extremities bilaterally. He responded to pin-prick throughout his body and extremities.
Follow-Up
Examination at six weeks post stroke finds power and deep tendon reflexes symmetrical bilaterally. He has regained sight in the right visual field. The rest sensory exam remains normal. He continues to experience difficulty communicating. His speech is low in volume and quantity and he perseverates frequently. His ability to repeat phrases after the examiner is still intact. Neuropsychological testing reveals extensive confusion, disorientation and memory loss remain in this patient. He could not assemble a pile of blocks to mimic that of an examiner. Nor could he draw or copy an accurate diagram of a house.
INSTRUCTIONS: Provide the BEST or MOST LIKELY answer to the following multiple choice questions.
1. The loss of power experienced by this patient is most likely due to a lesion of the:
a. Motor cortex
b. Premotor cortex
c. Corona radiata
d. Internal capsule
e. Ventral anterior thalamic nucleus
ANSWER
2. The loss of sight experienced by this patient is best termed:
a. Monocular blindness
b. Bitemporal hemianopsia
c. Homonymous hemianopsia
d. Homonymous hemianopsia with macula sparing
e. Visual neglect
ANSWER
3. The loss of vision expressed in this patient is most likely due to a lesion of the:
a. Optic nerve
b. Optic chiasm
c. Optic tract
d. Optic radiations
e. Visual cortex
ANSWER
4. The speech defect expressed in this patient is best termed:
a. Broca's aphasia
b. Wernicke's aphasia
c. Disconnection aphasia
d. Transcortical aphasia
e. Dysarthria
ANSWER
5. The altered pattern of facial expressions suggests a:
a. Supranuclear palsy of VII
b. Nuclear palsy of VII
c. Emotional facial palsy
d. Facial neglect syndrome
e. Facial apraxia
ANSWER
6. The defect in perception of geometric relationships present in this patient on neuropsychological testing is best termed:
a. Spatial neglect
b. Visual neglect
c. Spatial agnosia
d. Constructional apraxia
e. Spatial apraxia
ANSWER
7. In this patient, chomatolytic cell bodies will most likely be present in the:
a. Postcentral gyrus
b. Prefrontal cortex
c. Precentral gyrus
d. Visual cortex
e. Nucleus gracilis
ANSWER
8. In this patient, degenerating axons will most likely be present in the:
a. Internal capsule
b. Medial lemniscus
c. Superior cerebellar penducle
d. Corpus callosum
e. Stria terminalis
ANSWER
9. The best description of the distribution of this lesion is:
a. Focal and on the right
b. Focal and on the left
c. Multifocal
d. Diffuse
ANSWER
11. The best description of the temporal profile related to the pathology of this lesion is:
a. Acute and stable
b. Acute and progressive
c. Chronic and stable
d. Chronic and progressive
ANSWER