1997 Exam II Case 6

Chief Complaint:

This is a 32 year-old right handed female who presented with lower limb weakness and sensory loss, incontinence and altered personality.

History of Chief Complaint:

The patient was sitting upright in a chair when she experienced the sudden onset of a bifrontal headache. She also experienced difficulty speaking and became slightly obtunded. She remained obtunded for 48 hours after which some improvement in her communicative ability occurred. This examination is occurring at 1 week post stroke.

Medical History:

She was in good health up until she was diagnosed 6 years previous with mitral valve prolapse and hypertension. She has a 15 pack-year history of smoking.

Physical Exam:

She is an awake and confused woman who appears older than her stated age. She is well nourished and over weight with supple, moist skin. Her blood pressure is 150/92 mmHg, heart rate is 72 beats per minute and respirations are 15 per minute. There is a late systolic murmur preceded by a pronounced midsystolic click. Peripheral pulses are intact at the wrist and ankle. Her lungs are clear to auscultation with normal breath sounds. Her abdomen is much enlarged, soft and non-tender to palpation. There is no lymphadnopathy in the axillary or inguinal regions. She is incontinent of urine. She does not appear to experience any dysphagia when eating solid foods.

Neurologic Exam:

Mental Status: She is awake but not fully aware of her situation or her surroundings. She has a marked apathy for her condition. She sits quietly, responding to questions, but never initiating communication. She demonstrates no spontaneous activity and can remain very motionless for several hours. When forced to move or answer questions she will arouse and respond appropriately. She will eat when fed but does not sponataneously begin eating when food is presented on a tray. Her speech is very reduced in intensity and in quantity. She sounds telegraphic, with many broken words. Often she becomes stuck on one word and attempts to state it multiple times. She can, however, repeat complex phrases clearly following the examiner. She can follow three step commands with her right hand but not with her left hand. However, her left hand does not appear to be weak or paralyzed.

Cranial nerves: Her visual fields are full to confronation and both pupils responded to light. At rest, her eyes are deviated into the left hemisphere. She has a full range of motion in the left hemisphere but is unable to move her eyes past midline to enter the right hemisphere. Using the Doll's head reflex it is possible to move her eyes into the right hemisphere. She is responsive to touch and pinprick throughout her face. Corneal and gag reflexes are intact. She has symmetrical facial expressions; both corners of her mouth move in a grimace and both sides of her forehead and her eyebrows rise when attempting upward gaze. Hearing is intact to finger rub. Her shoulders move symmetrically and her tongue and palette are on the midline.

Motor exam: Her power is 5/5 in both left extremities and in the right upper extremity. In the right lower extremity she is 4/5 at the thigh and 3/5 at the knee and 2/5 at the ankle. She is able to use the right hand to write and to demonstrate common activities such as "waving goodbye". Although the left hand is capable of motion, she is unable to demonstrate "waving goodbye" with this hand.

Reflexes: Her deep tendon reflexes are 2/4 at the brachioradialis, biceps and triceps bilaterally and 2/4 at the ankle and knee on the left. Deep tendon reflexes are 3/5 at the ankle and 4/5 at the knee on the right. Sensory: She responds to touch and pin prick throughout both left extremities and her right upper extremity and right thigh. She appears to lack response to touch and pin prick over the right ankle and foot.

 

Questions

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