1997 Exam II Case 05

1997 Exam II CAse 05

Chief Complaint

This is a 47 year-old female with rapid onset of neurologic sequella subsequent to a myocardial infarction.

History of Chief Complaint:

On the afternoon of June 12, 1997 she suffered a myocardial infarction with residual mural thrombus. She was admitted to the ER in the late afternoon, but thrombolitic therapy was not initiated because the patient had dental surgery that morning. On the evening of June 13 the patient developed rapid visual and memory loss.

Medical History:

25 year history of birth control pills. 20 pack-year history of smoking.

Surgical History: none

Allergies: none

Medications: Birth control pill until admission.

Physical Exam:

Blood pressure 120/78, respiratory rate is 16, heart rate is 82. Neck is supple, without carotid bruits. There is no jugular vein distension present. Breath sounds are equal bilaterally with inspiratory wheezes which clear with coughing. Heart has regular rate and rhythm without clicks or murmurs. Abdomen is soft and not tender. Bowel sounds are quiet. Pulses are intact and equal at the axilla, and dorsal pedis.

Neurologic Exam:

Mental Status: She is awake and seated upright in the hospital bed. She knows her name and the names of her husband and children, but cannot explain why she is in the hospital nor can she correctly identify the time. Her speech is fluent but contains occasional meaningless or jargon phrases composed of neologisms. Repetition of words, phrases and sentences are intact. She can not read any printed material, however, she can identify writing on paper. She can write dictated phrases and words on paper but 5 minutes later cannot read what she has written. Her memory for past events is relatively intact. She knows her address, her parents names and her birth date. However, she has difficulty using the correct name on occasion and develops new, meaningless names to replace those she cannot articulate. She is unable to remember the names of any hospital staff for more than 5 minutes. Nor can she remember her room number in the hospital, but is capable of giving her home address. She is unable to name common objects such as a pen or key but can recognize these objects and can describe their correct usage.

Cranial Nerves: She has a complete range of eye movements and at rest her eyes are positioned on the midline. Her visual fields are intact in the left hemifield but are absent on the right except for a small section in the immediate center of the right hemifield. Both pupils respond to light. She responds to touch and pin-prick throughout her face. Facial expressions are full and symmetrical. Hearing is intact to finger rub. Her palette elevates on the midline and her tongue protrudes on the midline.

Motor Exam: Power is normal in all four extremities and there are no adventitious movements. Reflexes: Deep tendon reflexes are 2/4 in all extremities.

Sensory Exam: Position sense, vibratory sense and response to pin-prick are intact throughout her body and extremities.

Questions

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

Number: 1

The visual field defect experienced by this patient MOST likely arises from damage involving the:

a) Optic nerve

b) Optic chiasm

c) Lateral geniculate nucleus

d) Optic radiations

e) Occipital cortex

ANSWER

Number: 2

The loss of vision in this patient is best described as:

a) Monocular blindness

b) Bitemporal hemianopsia

c) Homonymous hemianopsia

d) Homonymous hemianopsia with macular sparing

e) Visual neglect

ANSWER

Number: 3

The memory defect experienced by this patient MOST likely arises from damage to the:

a) Prefrontal cortex

b) Cingulate cortex

c) Medial temporal lobe

d) Posterior parietal lobe

e) Insular lobe

ANSWER

Number: 4

The memory defect seen in this patient is BEST described as:

a) Anterograde amnesia

b) Retrograde amnesia

c) Global amnesia

d) Neglect

e) Abulia

ANSWER

Number: 5

The language defect epxressed in this patient is best described as:

a) Pure motor aphsasia

b) Pure sensory aphasia

c) Disconnection aphasia

d) Transcortical motor aphasia

e) Transcortical sensory aphasia

ANSWER

Number: 6

The inability of this patient to name common objects is best described as:

a) Agnosia

b) Neglect

c) Anomia

d) Achromatopsia

e) Agraphia

ANSWER

Number: 7

The patient's inability to read printed words in the face of an ability to write is best termed:

a) Neglect without agraphia

b) Agraphia with alexia

c) Alexia without agraphia

d) Agraphia without alexia

e) Alexic neglect

ANSWER

Number: 8

Of the following locations in this patient, chromatolytic neurons would be found in the:

a) Medial geniculate nucleus

b) Lateral geniculate nucleus

c) Ventroposterior thalamic nucleus

d) Ventrolateral thalamic nucleus

e) Ventroanterior thalamic nucleus

ANSWER

Number: 9

Of the following locations in this patient, degenerating axons would most likely be present in the:

a) Primary somatic sensory cortex

b) Primary motor cortex

c) Rostrum of the corpus callosum

d) Genu of the corpus callosum

e) Splenium of the corpus callosum

ANSWER

Number: 10

The lesion in this patient is best described as:

a) On the left and focal.

b) On the right and focal.

c) On the midline and focal.

d) On the midline and asymmetric.

e) On the midline and symmetric.

ANSWER

Number: 11

On imaging, occlusion would most likely be present in the vascular territory of the:

a) Anterior cerebral artery

b) Middle cerebral artery, upper division

c) Middle cerebral artery, lower division

d) Posterior cerebral artery

e) Posterolateral thalamus

ANSWER